Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential ...further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques.
MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life.
This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients.
This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).
Objective: To compare long-term outcomes between laparoscopic and robotic total mesorectal excisions (TMEs) for rectal cancer in a tertiary center. Background: Laparoscopic rectal cancer surgery has ...comparable long-term outcomes to the open approach, with several advantages in short-term outcomes. However, it has significant technical limitations, which the robotic approach aims to overcome. Methods: We included patients undergoing laparoscopic and robotic TME surgery between 2013 and 2021. The groups were compared after propensity-score matching. The primary outcome was 5-year overall survival (OS). Secondary outcomes were local recurrence (LR), distant recurrence (DR), disease-free survival (DFS), and short-term surgical and patient-related outcomes. Results: A total of 594 patients were included, and after propensity-score matching 215 patients remained in each group. There was a significant difference in 5-year OS (72.4% for laparoscopy vs 81.7% for robotic, P = 0.029), but no difference in 5-year LR (4.7% vs 5.2%, P = 0.850), DR (16.9% vs 13.5%, P = 0.390), or DFS (63.9% vs 74.4%, P = 0.086). The robotic group had significantly less conversion (3.7% vs 0.5%, P = 0.046), shorter length of stay 7.0 (6.0–13.0) vs 6.0 (4.0–8.0), P < 0.001), and less postoperative complications (63.5% vs 50.7%, P = 0.010). Conclusions: This study shows a correlation between higher 5-year OS and comparable long-term oncological outcomes for robotic TME surgery compared to the laparoscopic approach. Furthermore, lower conversion rates, a shorter length of stay, and a less minor postoperative complications were observed. Robotic rectal cancer surgery is a safe and favorable alternative to the traditional approaches.
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were ...identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to ...colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.
Purpose
To compare the short- and intermediate-term outcomes of open versus laparoscopic abdominoperineal resection (APR) for low rectal cancer.
Methods
Elective open and laparoscopic APRs were ...identified in a prospective database and were 1:1 propensity score-matched for age, ASA grade, tumour stage and type of neoadjuvant therapy. The short- and intermediate-term outcomes were compared.
Results
From January 2003 until June 2013, a total of 135 APRs (87 open, 48 laparoscopic) were identified and matched (
n
= 96, standardised mean difference of covariates <0.25). The thirty-day mortality, R0 rate, lymph nodes harvested and reoperations were similar. The length of the hospital stay was shorter in the laparoscopic group 10 versus 14 days,
p
= 0.004 (Mann–Whitney
U
test), Bonferroni-corrected significance level = 0.0083. The median follow-up was 4.6 (IQR: 2.0–6.0) years. The overall and recurrence-free 3-year survival rate estimates (Kaplan–Meier method; 95 % CI in brackets) were 71 % (59–86) and 57 % (44–73) in the open group versus 78 % (66–92) and 72 % (60–87) in the laparoscopic group, respectively
p
= 0.167 and
p
= 0.186 (log-rank test), respectively. The 3-year cumulative incidence of recurrence was 27 % (15–40) in the open group and 16 % (8–29) in the laparoscopic group
p
= 0.359 (Gray’s test).
Conclusions
Compared to open APR, laparoscopic APR provided a shorter length of hospital stay while showing no intermediate-term differences in the survival or cumulative incidence of recurrence.
Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ...ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future.
A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol.
Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements.
This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.
The gold standard surgical management of curable rectal cancer is proctectomy with total mesorectal excision. Adding preoperative radiotherapy improved local control
.
The promising results of ...neoadjuvant chemoradiotherapy raised the hopes for conservative, yet oncologically safe management, probably using local excision technique. This study is a prospective comparative phase III study, where 46 rectal cancer patients were recruited from patients attending Oncology Centre of Mansoura University and Queen Alexandra Hospital Portsmouth University Hospital NHS with a median follow-up 36 months. The two recruited groups were as follows:
g
roup (A), 18 patients who underwent conventional radical surgery by TME; and group (B), 28 patients who underwent trans-anal endoscopic local excision. Patients of resectable low rectal cancer (below 10 cms from anal verge) with sphincter saving procedures were included: cT1-T3N0. The median operative time for LE was 120 min versus 300 in TME
(p
<
0.001)
, and median blood loss was 20 ml versus 100 ml in LE and TME, respectively (
p
< 0.001). Median hospital stay was 3.5 days versus 6.5 days
(p
=
0.009)
. No statistically significant difference in median DFS (64.2 months for LE versus 63.2 months for TME,
p
=
0.85
) and median OS (72.9 months for LE versus 76.3 months for TME,
p
=
0.43
). No statistically significant difference in LARS scores and QoL was observed between LE and TME (
p
=
0.798
,
p
=
0.799
). LE seems a good alternative to radical rectal resection in carefully selected responders to neoadjuvant therapy after thorough pre-operative evaluation, planning and patient counselling.
The swift endorsement of the robotic surgical platform indicates that it might prevail as the preferred technique for many complex abdominal and pelvic operations. Nonetheless, use of the surgical ...robotic system introduces further layers of complexity into the operating theatre necessitating new training models. Instructive videos with relevant exposition could be optimal for early training in robotic surgery and the aim of this study was to develop consensus guidelines on how to report a robotic surgery video for educational purposes to achieve high quality educational video outputs that could enhance surgical training. A steering group prepared a Delphi survey of 46 statements, which was distributed and voted on utilising an electronic survey tool. The selection of committee members was designed to include representative surgical trainers worldwide across different specialties, including lower and upper gastrointestinal surgery, general surgery, gynaecology and urology. 36 consensus statements were approved and classified in seven categories: author’s information and video introduction, case presentation, demonstration of the surgical procedure, outcomes of the procedure, associated educational content, review of surgical videos quality and use of surgical videos in educational curricula. Consensus guidelines on how to report robotic surgery videos for educational purposes have been elaborated utilising Delphi methodology. We recommend that adherence to the guidelines presented could support advancing the educational quality of video outputs when designed for training.
Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the ...multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.
Abstract
Background
Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be ...supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team.
Material and methods
An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript.
Conclusion
Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.
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