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.
Background
The prognostic role of resection margins in pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to investigate the impact that global and individual resection margin ...status after pancreatic head resection for PDAC has on disease-free survival (DFS) and disease-specific survival (DSS).
Methods
Surgical specimens of pancreaticoduodenectomy/total pancreatectomy performed for PDAC were examined with a standardized protocol. Surgical margin status (biliary, pancreatic neck, duodenal, anterior and posterior pancreatic, superior mesenteric vein groove and superior mesenteric artery margins) was classified as the presence of malignant cells (1) directly at the inked surface (
R
1 direct), (2) within less than 1 mm (
R
1 ≤ 1 mm), or (3) with a distance greater than 1 mm (
R
0). Patients with a positive neck margin at the final histology were excluded from the study.
Results
Of the 362 patients included in the study, 179 patients (49.4 %) had an
R
0 resection, 123 patients (34 %) had an
R
1 ≤ 1 mm resection, and 60 patients (16.6 %) had an
R
1 direct resection. The independent predictors of DFS were
R
1 direct resection (hazard ratio HR, 1.49),
R
1 ≤ 1 mm resection (HR, 1.38), involvement of one margin (HR, 1.36), and involvement of two margins or more (HR, 1.55). When surgical margins were analyzed separately, only
R
1 ≤ 1 mm superior mesenteric vein margin (HR, 1.58) and
R
1 direct posterior margin (HR, 1.69) were independently associated with DFS.
Conclusions
Positive
R
status is an independent predictor of DFS (
R
1 direct and
R
1 ≤ 1 mm definitions) and of DSS (
R
1 direct). The presence of multiple positive margins is a risk factor for cancer recurrence and poor survival. Different surgical margins could have different prognostic roles.
The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and ...not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing.
The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks.
To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer.
ClinicalTrials.gov NCT3465982.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Neoadjuvant chemoradiotherapy followed by surgery is the mainstay treatment for locally advanced rectal cancer, leading to significant decrease in tumor size (downsizing) and a shift towards earlier ...disease stage (downstaging). Extensive histopathological work-up of the tumor specimen after surgery including tumor regression grading and lymph node status helped to visualize individual tumor sensitivity to chemoradiotherapy, retrospectively. As the response to neoadjuvant chemoradiotherapy is heterogeneous, however, valid biomarkers are needed to monitor tumor response. A relevant number of studies aimed to identify molecular markers retrieved from tumor tissue while the relevance of blood-based biomarkers is less stringent assessed. MicroRNAs are currently under investigation to serve as blood-based biomarkers. To date, no screening approach to identify relevant miRNAs as biomarkers in blood of patients with rectal cancer was undertaken. The aim of the study is to investigate the role of circulating miRNAs as biomarkers in those patients included in the TiMiSNAR Trial (NCT03465982). This is a biomolecular substudy of TiMiSNAR Trial (NCT03962088).
All included patients in the TiMiSNAR Trial are supposed to undergo blood collection at the time of diagnosis, after neoadjuvant treatment, after 1 month from surgery, and after adjuvant chemotherapy whenever indicated.
TiMiSNAR-MIRNA will evaluate the association of variation between preneoadjuvant and postneoadjuvant expression levels of miRNA with pathological complete response. Moreover, the study will evaluate the role of liquid biopsies in the monitoring of treatment, correlate changes in expression levels of miRNA following complete surgical resection with disease-free survival, and evaluate the relation between changes in miRNA during surveillance and tumor relapse.
Clinicaltrials.gov NCT03962088 . Registered on 23 May 2019.
In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on ...outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP).
Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions.
Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08–1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to −2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13–1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73–4.54; p < 0.001).
Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.
The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and ...not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing. The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks. To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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