Defining benchmarks for robotic-assisted low anterior rectum resection in low-morbid patients: a multicenter analysis

Purpose To define the best possible outcomes for robotic-assisted low anterior rectum resection (RLAR) using total mesorectal excision (TME) in low-morbid patients, performed by expert robotic surgeons in German robotic centers. The benchmark values were derived from these results. Methods The data was retrospectively collected from five German expert centers. After patient exclusion (prior surgery, extended surgery, no prior anastomosis, hand-sewn anastomosis), the benchmark cohort was defined (n = 226). The median with interquartile range was first calculated for the individual centers. The 75th percentile of the median results was defined as the benchmark cutoff and represents the “perfect” achievable outcome. This applied to all benchmark values apart from lymph node yield, where the cutoff was defined as the 25th percentile (more lymph nodes are better). Results The benchmark values for conversion and intraoperative complication rates were ≤ 4.0% and ≤ 1.4%, respectively. For postoperative complications, the benchmark was ≤ 28% for “any” and ≤ 18.0% for major complications. The R0 and complete TME rate benchmarks were both 100%, with a lymph node yield of > 18. The benchmark for rate of anastomotic insufficiency was < 12.5% and 90-day mortality was 0%. Readmission rates should not exceed 4%. Conclusion This outcome analysis of patients with low comorbidity undergoing RLAR may serve as a reference to evaluate surgical performance in robotic rectum resection.

Darmkrebs-OP: Auf die Erfahrung kommt es an

Diers J et al. Nationwide in-hospital mortality rate following rectum resection for rectal cancer according to annual hospital volume in Germany. BJS Open 2020; doi:10.1002/bjs5.50254

Preventive Loop Colostomy in Colorectal Cancer Surgery

Introduction. The problem of colonic anastomosis failure remains unsettled in colorectal surgery, since the use of various techniques of anastomotic protection does not preclude the development of complications.The aim of the study was to highlight surgical treatment outcomes of colorectal cancer using preventive stomas.Material and methods. The study included clinical outcomes of 248 patients with colorectal cancer. Group 1 included 85 patients who had a preventive colostomy after rectum resection and restoration of intestinal continuity. Group 2 (control) included 163 patients who had rectum resection without unloading stomas. The following parameters were evaluated in the study: gender, age, presence or absence of the preventive intestinal stoma, duration of stay in the surgical department, anastomotic failure.Results. In patients of group 1, colorectal anastomosis failure was manifested in 1 case (1.2%), in patients of group 2 - in 14 cases (8.6%). The average number of inpatient day in group 1 was 18, the average number of inpatient days in group 2 was 21.Conclusion. The application of a preventive intestinal stoma can reduce the incidence of failure, duration of hospital stay and improve long-term treatment outcomes

Mesh Migration Results in Asymptomatic Sigmoid Perforation as Long-Term Complication After Difficult TAPP: a Case Report

Hernia surgery is the most common surgical procedure worldwide. Complications are very rare and usually manifest in recurrence or chronic pain. We report a rare case of mesh migration 14 years after initially complicated transabdominal preperitoneal plastic for left-sided inguinal hernia. The mesh migration resulted in a covered sigmoid perforation, which was completely asymptomatic and only noticed as a chance finding in a staging CT scan prior to irradiation therapy. However, after the onset of immunosuppressive therapy, an exacerbation of chronic, localized inflammation was expected. Therefore, open surgical anterior rectum resection was performed, and after a short hospital stay, the patient could be discharged home free of complaints. This case report aims to raise awareness of possible long-term complications of hernia repair when using non-absorbable meshes.

Tumeurs précoces du rectum : résection endoscopique ou chirurgicale transanale ?

La prise en charge des tumeurs précoces du rectum (adénomes et adénocarcinomes classés usT1N0) est importante à connaître du fait de leur fréquence accrue. Le risque d’envahissement ganglionnaire étant faible (0 à 8%), l’exérèse locale est la résection de référence pour les tumeurs classées Tis et T1sm1, et une option séduisante pour les tumeurs T1sm2. La résection chirurgicale transanale par TEM (transanal endoscopic microsurgery) et la dissection sous-muqueuse (ESD) endoscopique sont les 2 techniques de référence pour les adénocarcinomes précoces. Avec des taux d’exérèse complète respectifs de 88,5% et 84%, la TEM et l’ESD sont recommandées indifféremment dans cette indication par l’Association Européenne de Chirurgie Endoscopique (EAES). Seules deux études monocentriques, rétrospectives et de faibles effectifs ont comparé ces deux techniques sans mettre en évidence de différence. Une étude nationale prospective est actuellement en cours.

Ghost Ileostomy in Advanced Ovarian Cancer: A Reliable Option

ObjectiveDiverting ileostomy (DI) has been proposed to reduce the incidence and consequences anastomotic leakage after bowel resection. In colorectal cancer treatment, ghost ileostomy (GI) has been proposed as an alternative to DI. Our objective was to report the results of GI associated with colorectal resection in the treatment of ovarian cancer.Materials and MethodsThis is an observational pilot study performed in a single institution. The main objective sought was to report the results of GI associated with colorectal resection in the treatment of ovarian cancer: 26 patients were included.ResultsModified posterior exenteration was performed in 24 cases (92.3%) and rectum resection in the 2 cases of relapse (7.7%). After the main procedure GI was created, to check up the anastomosis status, a sequential postoperative rectoscopy was performed on postoperative day 5 ± 1 (range, 4–7). Serum levels were monitored in first and third postoperative days just with a descriptive intention to establish its relationship with the rectoscopy findings. In 2 cases, rectoscopy demonstrated a leakage. During postoperative course, no other complication related with the GI or DI was observed. No case of clinical anastomotic leakage was found.ConclusionsTo the extent of our knowledge, this is the first study in which GI has been performed for the treatment of patients with ovarian cancer. Ghost ileostomy represents a real option that may reduce the number of ileostomies performed in ovarian cancer without increasing the morbimortality. Ghost ileostomy presents the advantages of DI while avoiding its drawbacks. It also seems to be a safe, feasible, and reproducible technique that does not add significant costs to the surgery.

Benefit of extraperitonization to prevent septic intraabdominal complications after distal rectal cancer surgery

Colorectal cancer is one of the most common oncological diseases. Surgery is the main treatment modality and laparoscopic colorectal resection has been gaining popularity over the past two decades. Neoadjuvant therapy is considered standard treatment for 2nd and 3rd stage distal rectal cancer. We present our retrospective study of 127 patients with anterior rectum resection (ARR) and total mesorectal excision (TME) for low rectal cancer operated on between 2012 and 2015 in two surgical wards. In all 59 laparoscopic ARR neoadjuvant therapy, intraabdominal drainage and ileostomy was performed, while extra-peritonization was done in 21 and no pre-sacral drainage was used. In the conventional group of 68 ARR, 21 had neo-adjuvant therapy, everyone has had extra-peritonization, pre-sacral drainage and no protective ileostomy performed. Early postoperative complications were registered in 25 patients, 24 related to the operation and 1 due to a recurrent brain stroke, all classified from I to III by Clavien Dindo scale. There were 9 anastomosis insufficiences: 6 in conventional and 3 in laparoscopic operations. In 3 patients (2 conventional and 1 laparoscopic) with low ARR and signs of peritoneal contamination re-laparotomy was performed with successive outcome. All patients survived. Our routine practice of extra-peritonization and pre-sacral-perianal drainage in open ARR eliminate the possibility of postoperative peritonitis after anastomosis insufficiency, limiting the infection to low pelvic phlegmona and local intra-abdominal pelvic infection in overlooked cases.