Segmental vs. extended colectomy: measurable differences in morbidity, function, and quality of life

Deloyers Technique for Restoration of Bowel Continuity Following Extended Left Hemicolectomy: A Comprehensive Analysis of 97 Cases and Literature Review

BACKGROUND

Deloyers technique addresses challenges in restoring bowel continuity after extended left hemicolectomies. Despite being first described in 1958, the technique remains underused, with limited data on long-term outcomes.

OBJECTIVE

To evaluate the indications of surgical and functional outcomes of the Deloyers technique and review existing literature.

DESIGN

Using a prospectively maintained database, patient demographics and perioperative data were collected. A telephone interview was conducted to assess bowel function, and statistical analysis identified factors affecting bowel function.

SETTINGS

Single tertiary care center.

PATIENTS

Patients who underwent the Deloyers technique from January 1995 to February 2023.

RESULTS

A total of 97 patients were included. The most common indications were colorectal cancer (50.5%) and diverticular disease (21.6%). In 53.6% of cases, Deloyers technique was performed at reoperations, and in 70.1% of cases, a diverting loop ileostomy was created. Early surgical complications occurred in 7.2% of patients, including 5 anastomotic leaks, 1 colonic conduit ischemia, and 1 small-bowel obstruction. Late complications occurred in 8.2% of cases, including 6 anastomotic strictures and 2 chronic leaks. There was no perioperative mortality. A total of 40 patients were interviewed and reported an average of 3.5 bowel movements per day and 0.5 at night; 17.5% of patients used bowel stoppers and 52.5% of patients reported that their bowel function did not impact their quality of life. Previous radiotherapy and anastomosis <8 cm from the anal verge were associated with having 4 or more bowel movements per day ( p < 0.01).

MAIN OUTCOME MEASURES

Postoperative morbidity and bowel function.

LIMITATIONS

Retrospective analysis of a heterogeneous group of patients with different pathologies and indications for surgery.

CONCLUSIONS

Deloyers technique is a safe and effective alternative for restoring bowel continuity after extended left hemicolectomy. Postoperative functional results are generally satisfactory, with more favorable outcomes noted in patients with higher anastomoses and those who have not undergone prior pelvic radiotherapy. See Video Abstract .

TCNICA DE DELOYERS PARA LA RECONSTRUCCIN DE LA CONTINUIDAD INTESTINAL TRAS HEMICOLECTOMA IZQUIERDA AMPLIADA ANLISIS EXHAUSTIVO DE CASOS Y REVISIN BIBLIOGRFICA

ANTECEDENTES:La técnica de Deloyers aborda los retos que plantea la reconstrucción de la continuidad intestinal tras hemicolectomías izquierdas ampliadas. A pesar de haber sido descrita inicialmente en 1958, la técnica sigue siendo poco utilizada, con datos limitados sobre sus resultados a largo plazo.OBJETIVO:Evaluar las indicaciones y los resultados tanto quirúrgicos como funcionales de la técnica de Deloyers y revisar la bibliografía existente.DISEÑO:Gracias a una base de datos mantenida de forma prospectiva, se recopiló información demográfica y perioperatoria de los pacientes. Se realizó una entrevista telefónica para evaluar la función intestinal y el análisis estadístico identificó los factores que afectaban a la función intestinal.ENTORNO:Un único centro de atención terciaria.PACIENTES:Aquellos sometidos a técnica de Deloyers entre enero de 1995 y febrero de 2023.RESULTADOS:Se incluyó a un total de 97 pacientes. Las indicaciones más frecuentes fueron cáncer colorrectal (50,5%) y enfermedad diverticular (21,6%). En el 53,6% de los casos se realizó DT en las reoperaciones y en el 70,1% se creó una ileostomía de protección. Se encontraron complicaciones quirúrgicas tempranas en 7,2% de los pacientes, incluidas cinco fugas anastomóticas, una isquemia segmentaria de colon y una obstrucción del intestino delgado. Se describen complicaciones tardías en 8,2% de los pacientes, entre ellas 6 estenosis anastomóticas y 2 fugas crónicas. No hubo mortalidad perioperatoria. Se entrevistó a un total de 40 pacientes, que declararon una media de 3,5 deposiciones al día y 0,5 por la noche; el 17,5% utilizó tapones intestinales y el 52,5% de los pacientes declaró que su función intestinal no repercutía en su calidad de vida. La radioterapia previa y la anastomosis a menos de ocho cm del borde anal fueron asociadas con la evacuación de cuatro o más deposiciones al día ( p < 0,01).MEDIDAS DE RESULTADOS PRINCIPALES:Morbilidad postoperatoria y función intestinal.LIMITACIONES:Análisis retrospectivo de un grupo heterogéneo de pacientes con diferentes patologías e indicaciones quirúrgicas.CONCLUSIÓN:La técnica de Deloyers es una alternativa segura y eficaz para restaurar la continuidad intestinal tras una hemicolectomía izquierda ampliada. Los resultados funcionales postoperatorios son generalmente satisfactorios, observándose resultados más favorables en pacientes con anastomosis más altas y en aquellos que no han recibido radioterapia pélvica previa. (Traducción-Dr. Xavier Delgadillo ).

British Society of Gastroenterology practice guidance on the management of acute and chronic gastrointestinal symptoms and complications as a result of treatment for cancer

BACKGROUND

Survival rates after a diagnosis of cancer are improving. Poorly managed gastrointestinal (GI) side effects can interfere with delivery of curative cancer treatment. Long-term physical side effects of cancer therapy impinge on quality of life in up to 25% of those treated for cancer, and GI side effects are the most common and troublesome.

AIM

To provide comprehensive, practical guidance on the management of acute and chronic luminal gastrointestinal symptoms arising during and after treatment for cancer METHODS: A multidisciplinary expert group including patients treated for cancer, divided into working parties to identify, and synthesise recommendations for the optimal assessment, diagnosis and appropriate interventions for luminal GI side effects of systemic and local cancer therapies. Recommendations were developed using the principles of the BMJ AGREE II reporting.

RESULTS

103 recommendations were agreed. The importance of the patient perspective and what can be done to support patients are emphasised. Key physiological principles underlying the development of GI toxicity arising from cancer therapy are outlined. Individual symptoms or symptom clusters are poor at distinguishing the underlying cause(s), and investigations are required if empirical therapy does not lead rapidly to significant benefits. Patients frequently have multiple GI causes for symptoms; all need to be diagnosed and optimally treated to achieve resolution. Investigations and management approaches now known to be ineffective or of questionable benefit are highlighted.

CONCLUSIONS

The physical, emotional and financial costs to individuals, their families and society from cancer therapy can be considerable. Identifying and signposting affected patients who require specialist services is the role of all clinicians. Progress in the treatment of cancer increasingly means that patients require expert, multidisciplinary supportive care providing effective and safe treatment at every stage of the cancer journey. Development of such expertise should be prioritised as should the education of health professionals and the public in what, when and how acute and chronic gastrointestinal symptoms and complications should be managed.

Emerging therapeutic strategies in Lynch syndrome-associated colorectal cancer and the role of MMR testing

Lynch syndrome is the most common hereditary cancer predisposition, accounting for 1-5% of colorectal cancer cases, and is driven by germline mutations in DNA mismatch repair genes. Despite established diagnostic criteria, such as the Amsterdam guidelines, Lynch syndrome remains largely underdiagnosed. To address this gap, universal tumour screening has been introduced for all newly diagnosed cases of colorectal cancer and endometrial cancer, significantly improving early detection. The surgical management of colorectal cancer in patients with Lynch syndrome remains controversial. While extended colectomy reduces the risk of metachronous colorectal cancer, surgical strategies must be carefully individualised based on patient-specific factors. Chemoprevention with aspirin has shown promise in reducing the risk of colorectal cancer, with ongoing trials investigating optimal dosing. Immunotherapy, particularly immune checkpoint inhibitors, has revolutionised the treatment of Microsatellite Instability-High/deficient Mismatch Repair colorectal cancer, offering durable responses and significant survival benefits. In addition, the neoadjuvant use of immune checkpoint inhibitors is paving the way for non-surgical interventions, potentially transforming the management of colorectal cancer in patients with Lynch syndrome. A multidisciplinary approach and continued research are essential to optimise cancer prevention, treatment and quality of life for people with Lynch syndrome.

Practice Patterns and Trends in the Surgical Management of Mismatch Repair Deficient Colon Cancer

INTRODUCTION

Defects in the DNA mismatch repair (MMR) pathway can predispose individuals to colorectal cancer (CRC), with germline mutations in this pathway leading to Lynch syndrome. Consequently, universal MMR testing is recommended for all newly diagnosed CRC patients to detect mismatch repair deficient (MMR-D) tumors, enabling informed treatment decisions. Given the increased potential for metachronous disease in patients with Lynch syndrome, the current guidelines for surgical management of Lynch-associated colon cancer recommend extended resection in patients under age 60.

METHODS

A retrospective analysis of nonmetastatic CRC was performed from the National Cancer Database to evaluate the current trends and practice patterns in the surgical management of MMR-D colon cancer, as well as assess the factors influencing choice of surgical procedure.

RESULTS

From 2018 to 2020, 98,112 nonmetastatic CRC patients were identified, with 19.93% being MMR-D. MMR-D colon cancer patients were more likely to undergo extended resection than those with mismatch repair proficient tumors (9.4% versus 4.2%, P < 0.001). When accounting for approximately one-fourth of MMR-D colon cancers being attributable to Lynch syndrome, the frequency of extended resection was less than expected (9.4% versus 25%, P < 0.001). MMR-D patients under age 60 were more likely to undergo extended resection than those over age 60 (9% versus 3%) (odds ratio [OR] 3.57, 95% confidence interval [CI] 3.06-4.15). Several factors were associated with decreased rate of extended resection: uninsured (OR 0.42, 95% CI 0.21-0.84), Black race (OR 0.54, 95% CI 0.35-0.82), treatment at nonacademic centers (OR 0.74, 95% CI 0.56-0.97), and crowfly distance >25 miles (OR 1.98, 95% CI 1.14-3.45).

CONCLUSIONS

These findings provide valuable insight into the current surgical practice patterns in the management of MMR-D colon cancers and possibly colon cancers associated with Lynch syndrome.

Clinical features, surgical treatment strategy, and feasibility of minimally invasive surgery for synchronous and metachronous multiple colorectal cancers: A 14-year single-center experience

BACKGROUND

Patients with a history of colorectal cancer (CRC) are at increased risk of developing secondary synchronous/metachronous CRCs. The role of minimally invasive surgery (MIS) for multiple CRCs remains unclear. This study aimed to evaluate the short-term outcomes of MIS in patients with multiple CRCs and elucidate their clinical characteristics.

METHODS

This retrospective study reviewed CRC patients who underwent MIS between 2010 and 2023. Multiple CRC cases were categorized into synchronous and metachronous cohorts. Demographics, pathological findings, and perioperative outcomes were analyzed. Propensity score matching (PSM) analysis was performed as appropriate.

RESULTS

A total of 1,272 patients met the inclusion criteria, with 99 (7.8%) having multiple CRCs (75 synchronous and 24 metachronous). Multiple CRC patients had a higher prevalence of strong family history (8.1% vs. 1.0%, P < 0.001) and right-sided colon cancer (55.6% vs. 34.4%, P < 0.001) compared to solitary CRC patients. MSI-high/MMR-deficient status, including Lynch syndrome, was frequently observed among patients with multiple CRCs. Synchronous CRCs requiring double-anastomosis were associated with longer operation times (P = 0.03) and increased blood loss (P = 0.03) compared to those with a single-anastomosis. In the metachronous cohort, repeat operation patterns were categorized based on tumor location and sacrificed arteries. Preservation of the left-colic artery avoided extended colectomy in some patients. Patients with multiple CRC involving rectal cancer had a higher anastomotic leakage (AL) rate (17.6% vs. 5.7%, P < 0.01); however, this difference in AL rate disappeared after PSM (8.8% vs. 8.8%, P = 1.0). In patients with multiple CRCs, AL has not been observed ever since the indocyanine green fluorescence imaging was implemented.

CONCLUSIONS

MIS is feasible for multiple CRCs, with perioperative outcomes comparable to those for solitary CRCs. Preservation of critical arteries may benefit patients at high risk of secondary CRCs, particularly those with a strong family history of CRC, right-sided tumors, or MSI-high/MMR-deficient profiles, including Lynch syndrome.

Chinese national clinical practice guidelines on prevention, diagnosis and treatment of early colorectal cancer

BACKGROUND

The incidence and mortality of colorectal cancer (CRC) in China are increasing in recent years. The clarified pathogenesis and detectable precancerous lesions of CRC make it possible to prevent, screen, and diagnose CRC at an early stage. With the development of endoscopic and surgical techniques, the choice of treatment for early CRC is also worth further discussion, and accordingly, a standard follow-up program after treatment needs to be established.

METHODS

This clinical practice guideline (CPG) was developed following the recommended process of the World Health Organization, adopting Grading of Recommendations Assessment, Development and Evaluation (GRADE) in assessing evidence quality, and using the Evidence to Decision framework to formulate clinical recommendations, thereby minimizing bias and increasing transparency of the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guides to ensure the guideline's completeness and transparency.

RESULTS

This CPG comprises 46 recommendations concerning prevention, screening, diagnosis, treatment, and surveillance of CRC. In these recommendations, we have indicated protective and risk factors for CRC and made recommendations for chemoprevention. We proposed a suitable screening program for CRC based on the Chinese context. We also provided normative statements for the diagnosis, treatment, and surveillance of CRC based on existing clinical evidence and guidelines.

CONCLUSIONS

The 46 recommendations in this CPG are formed with consideration for stakeholders' values and preferences, feasibility, and acceptability. Recommendations are generalizable to resource-limited settings with similar CRC epidemiology pattern as China.

Precision Oncology in Gastrointestinal and Colorectal Cancer Surgery

Precision medicine is used to treat gastrointestinal malignancies including esophageal, gastric, small bowel, colorectal, and pancreatic cancers. Cutting-edge assays to detect and treat these cancers are active areas of research and will soon become standard of care. Colorectal cancer is a prime example of precision oncology as disease site is no longer the final determinate of treatment. Here, the authors describe how leveraging an understanding of tumor biology translates to individualized patient care using evidence-based practices.

Influence of the type of anatomic resection on anastomotic leak after surgery for colon cancer

INTRODUCTION

Anastomotic leak (AL) after colon cancer resection is feared by surgeons because of its associated morbidity and mortality. Considerable research has been directed at predictive factors for AL, but not the anatomic type of colonic resection. Anecdotally, certain types of resection are associated with higher leak rates although there remains a paucity of data on this. This study aimed to determine the AL rate for different types of colon cancer resection to inform decisions regarding the choice of operation.

METHODOLOGY

Retrospective analysis of Bowel Cancer Outcome Registry (BCOR) for all colonic cancer resections with anastomosis between January 2007 and December 2020. Demographic, patient, tumour and outcome data were analysed. AL rates were compared among the different colonic procedures with both univariate and multivariate analysis.

RESULTS

20 191 patients who underwent resection with anastomosis for cancer were included in this study. Of these 535 (2.6%) suffered ALs. While the univariate analysis found male sex, procedure type, symptomatic cancers, emergency surgery, unsupervised registrars, conversion to open surgery, medical complications and higher TNM staging were associated with AL, multivariate analysis, found only procedure type remained a significant predictor of AL (total colectomy (OR 4.049, P<0.001), subtotal colectomy (OR 2.477, P<0.001) and extended right hemicolectomy (OR 2.171, P < 0.001)).

CONCLUSION

AL is more common in extended colonic resections. With growing evidence of similar oncological outcomes between subtotal colectomy and left hemicolectomy for splenic flexure cancers, more limited resections should be considered. The type of colonic resection should be integrated into prediction tools for AL.

The colon does not reach! A technical note with tricks to avoid colorectal anastomoses under tension

AIM

We describe two options for colorectal anastomosis suitable in cases when the colon would reach the pelvis under tension.

METHOD

Deloyers procedure and the retro-ileal colorectal anastomosis are presented, focusing on practical tips and tricks to perform them. Insights on patients who underwent the procedures are provided to demonstrate the advantages and feasibility of the techniques.

RESULTS

Each step of both techniques is detailed. Ten patients underwent Deloyers procedure and nine underwent retro-ileal anastomosis at our unit. A minimally invasive approach was attempted in 13 patients, of whom five required conversion to open surgery due to the technical complexity of the abdominal procedure. Colorectal anastomosis was successfully performed in all patients. There were no major intra-operative complications, although five patients had postoperative complications requiring further treatment.

CONCLUSIONS

Both techniques are effective in patients at risk of receiving a colorectal anastomosis under tension, and a minimally invasive approach can be used. However, owing to the complexity of surgery in this group of patients, the perioperative morbidity is not negligible. Careful postoperative management is advisable, and patients should be informed of the risks. In expert hands, the outcomes are acceptable, avoiding an ileorectal anastomosis and its constraints.

Focal Cancer in Colitis

Colorectal cancer (CRC) is a known complication of inflammatory bowel disease (IBD). Widely accepted guidelines recommend that patients with ulcerative colitis diagnosed with CRC undergo total proctocolectomy with or without ileal pouch-anal anastomosis, and that patients with Crohn's disease and CRC undergo either total colectomy or proctocolectomy. These approaches are ideal for preventing synchronous and metachronous cancer, minimizing risk of refractory colitis requiring reoperation, and is the appropriate treatment for the vast majority of patients with IBD who are diagnosed with CRC and require surgical intervention. Segmental colectomy, however, may be considered in select patients with IBD and CRC, specifically in elderly patients with short disease duration, in patients with mild colitis identified preoperatively, in patients with high operative risk and prohibitive comorbidities, and in patients whose CRC appears to be sporadic as opposed to colitis-associated. Patients undergoing segmental resection must be closely surveilled postoperatively for dysplasia, recurrent cancer, and refractory colitis.

Surgical management strategies for colorectal malignancies of the splenic flexure - A systematic review and network meta-analysis

BACKGROUND

Extended right hemicolectomy (ERHC) or left hemicolectomy (LHC) are accepted as the standard-of-care for colonic tumours of the splenic flexure. Lymphatic drainage at this site is poorly defined and subject to significant heterogeneity. Nevertheless, emerging evidence demonstrates the potential oncological safety of segmental splenic flexure colectomy (SFC).

AIM

To perform a systematic review and network meta-analysis (NMA) to compare outcomes following ERHC, LHC and SFC for splenic flexure tumours (SFTs).

METHODS

A systematic review was performed as per PRISMA guidelines. NMA was performed using R Shiny and Netmeta packages.

RESULTS

A total of 13 studies, involving 6176 patients (ERHC n = 785; LHC n = 1527; SFC n = 3864) were included in the NMA. There was no difference in overall survival (OS) (SFC vs LHC Hazard Ratio [HR] 1.0, 95% Credible Interval [CrI] 0.76,1.34; SFC vs ERHC HR 1.18, 95% CrI 0.85,1.58) between the groups. SFC had a shorter operation time (Mean 176.37 min; Mean Difference [MD] SFC vs LHC 20.34 min 95% CrI 10.9, 29.97; SFC vs ERHC MD 22.19 95% CrI 11.09, 33.29) but also had a lower average lymph node yield (LNY) compared with ERHC (MD 7.15, 95% CrI 5.71, 8.60). ERHC had a significantly higher incidence of post-operative ileus (Odds Ratio [OR] 3.47, 95% CrI 1.11, 10.84). There was also no difference observed for minimally invasive approaches, anastomotic leak rate, perioperative mortality, reoperation rates or length of stay.

CONCLUSIONS

While SFC may allow for reduced operative duration and improved bowel function postoperatively. SFC, LHC, ERHC are all acceptable approaches for curative resection of cancers of the splenic flexure, with no difference in OS observed. Thus, surgeon preference and candidate-specific factors will likely determine the management of SFTs.

Short- and long-term results of open vs laparoscopic multisegmental resection and anastomosis for synchronous colorectal cancer located in separate segments

BACKGROUND

It remains unclear whether laparoscopic multisegmental resection and anastomosis (LMRA) is safe and advantageous over traditional open multisegmental resection and anastomosis (OMRA) for treating synchronous colorectal cancer (SCRC) located in separate segments.

AIM

To compare the short-term efficacy and long-term prognosis of OMRA as well as LMRA for SCRC located in separate segments.

METHODS

Patients with SCRC who underwent surgery between January 2010 and December 2021 at the Cancer Hospital, Chinese Academy of Medical Sciences and the Peking University First Hospital were retrospectively recruited. In accordance with the inclusion and exclusion criteria, 109 patients who received right hemicolectomy together with anterior resection of the rectum or right hemicolectomy and sigmoid colectomy were finally included in the study. Patients were divided into the LMRA and OMRA groups (n = 68 and 41, respectively) according to the surgical method used. The groups were compared regarding the surgical procedure's short-term efficacy and its effect on long-term patient survival.

RESULTS

LMRA patients showed markedly less intraoperative blood loss than OMRA patients (100 vs 200 mL, P = 0.006). Compared to OMRA patients, LMRA patients exhibited markedly shorter postoperative first exhaust time (2 vs 3 d, P = 0.001), postoperative first fluid intake time (3 vs 4 d, P = 0.012), and postoperative hospital stay (9 vs 12 d, P = 0.002). The incidence of total postoperative complications (Clavien-Dindo grade: ≥ II) was 2.9% and 17.1% (P = 0.025) in the LMRA and OMRA groups, respectively, while the incidence of anastomotic leakage was 2.9% and 7.3% (P = 0.558) in the LMRA and OMRA groups, respectively. Furthermore, the LMRA group had a higher mean number of lymph nodes dissected than the OMRA group (45.2 vs 37.3, P = 0.020). The 5-year overall survival (OS) and disease-free survival (DFS) rates in OMRA patients were 82.9% and 78.3%, respectively, while these rates in LMRA patients were 78.2% and 72.8%, respectively. Multivariate prognostic analysis revealed that N stage [OS: HR hazard ratio (HR) = 10.161, P = 0.026; DFS: HR = 13.017, P = 0.013], but not the surgical method (LMRA/OMRA) (OS: HR = 0.834, P = 0.749; DFS: HR = 0.812, P = 0.712), was the independent influencing factor in the OS and DFS of patients with SCRC.

CONCLUSION

LMRA is safe and feasible for patients with SCRC located in separate segments. Compared to OMRA, the LMRA approach has more advantages related to short-term efficacy.

Surgical management of splenic flexure cancer: is there an optimal technique? A bi-national registry analysis

BACKGROUND

Splenic flexure tumours (SFC) are uncommon and present at more advanced disease stages. The optimal surgical technique for SFC remains controversial. We sought to compare the short-term outcomes of a left hemicolectomy (LHC) versus an extended resection (subtotal colectomy, STC) for SFCs.

METHODS

A retrospective analysis using the Binational Colorectal Cancer Audit (BCCA) registry was performed. All patients with SFC who underwent elective or emergency surgery for a SFC between 2010 and 2021 were included. Primary outcomes included short-term inpatient complications. Secondary outcomes included survival outcomes.

RESULTS

Six hundred and ninety-nine patients underwent resections for SFCs. A LHC was more common, performed in 64.1%. Patients having a LHC were significantly older, with proportionally more LHCs done laparoscopically. Overall grade III/IV complications were similar between both operations. Prolonged ileus and return to theatre were significantly higher in patients undergoing a STC. On multivariate analysis, anastomotic leak and overall grade III/IV complications were not independently associated with the type of operation. There was no difference in medial survival based on type of operation. Higher tumour stage (Stage III/IV) were independently associated with worse survival.

CONCLUSION

Segmental and extended resections are both oncologically sound procedures for SFCs. Segmental resections are associated with lower rates of prolonged ileus.

Surgical resection for second primary colorectal cancer: a population-based study

Background

Second primary colorectal cancer (CRC) is attributed to a crucial component of the CRC population. Still, its treatments remain unclear due to the troublesome conditions originating from multiple primary cancers and the lack of quality evidence. This study aimed to determine that which type of surgical resection is the eligible treatment for second primary CRC among patients with a prior cancer history.

Methods

This cohort study retrospectively collected patients with second primary stage 0-III CRC in the Surveillance, Epidemiology, and End Results database from 2000 to 2017. Prevalence of surgical resection in second primary CRC, overall survival (OS) and disease-specific survival (DSS) of patients who received different surgical interventions were estimated.

Results

A total of 38,669 patients with second primary CRC were identified. Most of the patients (93.2%) underwent surgical resection as initial treatment. Approximately 39.2% of the second primary CRCs (N = 15,139) were removed with segmental resection, while 54.0% (N = 20,884) were removed through radical colectomy/proctectomy. Surgical resection was associated with a significantly favorable OS and DSS compared to those not receiving any surgical operations for second primary CRC [OS: adjusted Hazard ratios (adjusted HR): 0.35; 95% CI: 0.34-0.37, p < 0.001; DSS: adjusted HR: 0.27; 95% CI: 0.25-0.29, p < 0.001]. Segmental resection considerably outperformed radical resection in terms of OS and DSS (OS: adjusted HR: 0.97; 95% CI: 0.91-1.00, p = 0.07; DSS: adjusted HR: 0.92; 95% CI: 0.87-0.97, p = 0.002). Segmental resection was also associated with a significantly reduced cumulative mortality of postoperative non-cancer comorbidities.

Conclusion

Surgical resection demonstrated excellent oncological superiority for second primary CRC and was used to remove the vast majority of second primary CRCs. In comparison to radical resection, segmental resection offered a better prognosis and reduced postoperative non-cancer complications. The second primary colorectal cancers should be resected if the patients can afford surgical operations.

Young-onset colorectal cancer

In the past decades the incidence of colorectal cancer (CRC) in people under the age of 50 years has increased, which is referred to as early-onset CRC or young-onset CRC (YO-CRC). YO-CRC is expected to account for 11% of colon cancers and 23% of rectal cancers by 2030. This trend is observed in different parts of the world and in both men and women. In 20% of patients with YO-CRC, a hereditary cancer syndrome is found as the underlying cause; however, in the majority of patients no genetic predisposition is present. Beginning in the 1950s, major changes in lifestyle such as antibiotic use, low physical activity and obesity have affected the gut microbiome and may be an important factor in YO-CRC development. Owing to a lack of screening, patients with YO-CRC are often diagnosed with advanced-stage disease. Long-term treatment-related complications should be taken into account in these younger patients, making the more traditional sequential approaches of drug therapy not always the most appropriate option. To better understand the underlying mechanism and define relationships between environmental factors and YO-CRC development, long-term prospective studies are needed with lifestyle data collected from childhood.

Surgical outcomes of left hemicolon sparing resection versus extensive resection in treating synchronous colorectal cancer involving the right-sided colon and sigmoid colon or rectum

BACKGROUND

There are different surgical strategies that can treat synchronous colorectal cancer (SCRC) involving separate segments, namely extensive resection (EXT) and left hemicolon-sparing resection (LHS). We aim to comparatively analyze short-term surgical results, bowel function, and long-term oncological outcomes between SCRC patients treated with the two different surgical strategies.

METHODS

One hundred thirty-eight patients with SCRC lesions located in the right hemicolon and rectum or sigmoid colon were collected at the Cancer Hospital, Chinese Academy of Medical Sciences, and the Peking University First Hospital from January 2010 to August 2021 and divided into EXT group (n = 35) and LHS group (n = 103), depending on their surgical strategies. These two groups of patients were compared for postoperative complications, bowel function, the incidence of metachronous cancers, and prognosis.

RESULTS

The operative time for the LHS group was markedly shorter compared with the EXT group (268.6 vs. 316.9 min, P = 0.015). The post-surgery incidences of total Clavien-Dindo grade ≥ II complications and anastomotic leakage (AL) were 8.7 vs. 11.4% (P = 0.892) and 4.9 vs. 5.7% (P = 1.000) for the LHS and EXT groups, respectively. The mean number of daily bowel movements was significantly lower for the LHS group than for the EXT group (1.3 vs. 3.8, P < 0.001). The proportions of no low anterior resection syndrome (LARS), minor LARS, and major LARS for the LHS and EXT groups were 86.5 vs. 80.0%, 9.6 vs. 0%, and 3.8 vs. 20.0%, respectively (P = 0.037). No metachronous cancer was found in the residual left colon during the 51-month (median duration) follow-up period. The overall and disease-free survival rates at 5 years were 78.8% and 77.5% for the LHS group and 81.7% and 78.6% for the EXT group (P = 0.565, P = 0.712), respectively. Multivariate analysis further confirmed N stage, but not surgical strategy, as the risk factor that independently affected the patients' survival.

CONCLUSIONS

LHS appears to be a more appropriate surgical strategy for SCRC involving separate segments because it exhibited shorter operative time, no increase in the risk of AL and metachronous cancer, and no adverse long-term survival outcomes. More importantly, it could better retain bowel function and tended to reduce the severity of LARS and therefore improve the post-surgery life quality of SCRC patients.

Surgery for synchronous and metachronous colorectal cancer: segmental or extensive colectomy?

PURPOSE

To assess the impact of surgical approach on morbidity, mortality, and the oncological outcomes of synchronous (SC) and metachronous (MC) colorectal cancer (CRC).

METHODS

All patients undergoing resection for double location CRC (SC or MC) between 2006 and 2020 were included. The exclusion criteria were polyposis or SC located on the same side.

RESULTS

Sixty-seven patients (age, 64.8 years; male, 78%) with SC (n = 41; 61%) or MC (n = 26; 39%) were included. SC was treated with segmental colectomy (right and left colectomy/proctectomy; n = 19) or extensive colectomy (subtotal/total colectomy or restorative proctocolectomy with pouch; n = 22). Segmental colectomy was associated with a higher incidence of anastomotic leakage (47.4 vs. 13.6%; p = 0.04) and a higher rate of medical morbidity (47.4 vs. 16.6%; p = 0.04). The mean number of lymph nodes harvested was similar. For MC, the second cancer was treated by iterative colectomy (n = 12) or extensive colectomy (n = 14) and there was no significant difference in postoperative outcomes between the two surgical approaches. The median follow-up period was 42.4 ± 29.1 months. The 5-year overall and disease-free survival of the SC and MC groups did not differ to a statistically significant extent.

CONCLUSIONS

Extensive colectomy should be preferred for SC to reduce morbidity and improve the prognosis. In contrast, iterative colectomy can be performed safely for patients with MC.

[Surgical strategies for hereditary colorectal cancer]

Hereditary colorectal cancer (hCRC) represents a major diagnostic and therapeutic challenge. In addition to the usual diagnostic methods, the family history, histological confirmation and mutation analysis play an important role in identifying the type of hereditary CRC. The diagnosis and classification of hCRC are carried out based on the anamnesis, clinical presentation and histology and the further treatment is determined depending on the underlying type of hCRC. For familial adenomatous polyposis (FAP) coloproctomucosectomy after the end of puberty is always recommended, whereas the treatment recommendations for other forms, such as attenuated FAP (aFAP), MUTYH-associated polyposis (MAP) and hereditary nonpolyposis colon cancer (HNPCC, Lynch syndrome), range from close surveillance and endoscopic control, through segmental resection up to colectomy. Irrespective of the type of hCRC, the treatment regimens necessitate an individualized approach and require close interdisciplinary cooperation. When colorectal resection is performed, minimally invasive procedures should principally be prioritized and some studies could demonstrate a potential benefit of robotic surgery compared to laparoscopy.

Best surgical approach for splenic flexure colon cancers: Extended versus segmental resection?

BACKGROUND

The optimal surgical treatment approach for splenic flexure colon cancers remains controversial regarding the type of resection.

METHODS

We hypothesized that both extended and segmental resections have similar surgical and oncologic outcomes. A retrospective review of prospectively collected database was performed on all patients who had colectomy for splenic flexure colon cancer between 1996 and 2018.

RESULTS

Of 142 patients, 119 underwent extended resection; therefore, this group was compared with the group which underwent segmental resection (n = 23). The groups were similar in age, sex, ASA scores, operative times, estimated blood loss, hospital length of stay, and postoperative complication rates (p > 0.05). Median follow-up was 9.58 years (IQR:5.46-16.48). Multivariable regression models demonstrated no significant association between resection approach and disease-free survival (HR 1.63 [95%CI:0.91-2.92]), as well as overall survival (HR 1.80 [95%CI:0.97; 3.36]).

CONCLUSION

In the treatment of splenic flexure colon cancer, segmental colon resections have similar oncologic outcomes when compared to extended colectomies.

Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Cecal perforations due to descending colon obstruction (closed loop): a case report and review of the literature

BACKGROUND

Cases of large bowel closed-loop phenomenon with cecal perforation are extremely rare, especially when extracolonic epiploic appendage and peritoneal bands are the cause. However, sporadic cases exist in the literature with various presentations, but very few occur in patients in the abdomen without a previous scar.

CASE PRESENTATION

An 89-year-old Sudanese farmer was admitted to the emergency department with 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. Given his clinical presentation and assessment, he was diagnosed with peritonitis due to a perforated viscus in a virgin abdomen. Operative exploration revealed an extraluminal left-sided omento-epiploic band that resulted in closed-loop colonic obstruction with secondary multiple cecal perforations. Standard right hemicolectomy with adhesiolysis was done. Postoperative wound infection and hypoalbuminemia were treated, and the patient was discharged on postoperative day 9 on a regular oral diet.

CONCLUSIONS

Although this condition is rare, it can be extremely dangerous, requiring prompt investigation and surgical intervention. It usually occurs secondary to raised intraluminal pressure with subsequent ischemia of the cecal wall. Through this case report, we aim to reflect on this rare experience, shedding light on the benign, extracolonic pathologies that can be life threatening or even fatal.

Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection

BACKGROUND

Restoration of bowel continuity after left extended colectomy may be challenging because the remaining colon may not reach the rectal stump without tension to perform a safe anastomosis. Performing a total colectomy with ileorectal anastomosis (IRA) is an option, but the quality of life can be significantly impaired due to loose stools and an increase in bowel frequency. In contrast, the preservation of the right colon and ileocaecal valve in the Deloyers procedure (DP) might ensure a better stool consistency and bowel transit, and therefore a superior quality of life.

MATERIALS AND METHODS

A transverse study comparing patients that underwent DP versus patients with an IRA was performed. Postoperative morbidity, mortality, functional outcomes, and quality of life were analysed between groups. Quality of life after the surgical procedure was assessed with the SF-36 V2® health survey.

RESULTS

A total of 16 patients with DP and 32 with IRA were included. The groups had similar demographic characteristics concerning age, sex, body mass index, ASA classification, diagnosis and Charlson comorbidity index. The median follow-up was 55 months for DP and 99 months for IRA. Postoperative complications were similar in both groups. Patients in the DP group had fewer bowel movements (P = 0.01), tenesmus (P = 0.04) and use of loperamide (P = 0.03). DP patients achieved better scores in physical pain (P = 0.02) and general health (P < 0.01) than IRA patients.

CONCLUSIONS

DP for intestinal continuity restoration after extended left colon resection is a safe and feasible alternative, possibly achieving better functional outcomes and quality-of-life compared to IRA.

The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer

PURPOSE

The present study assessed postoperative bowel dysfunction in Japanese patients with rectal cancer, including patients who underwent preoperative radiotherapy (RT).

METHODS

A total of 277 rectal cancer patients who underwent primary resection were included in the analyses. A questionnaire survey was administered using the low anterior resection syndrome (LARS) score and Wexner score. Scores were determined one year after rectal surgery or diverting ileostomy closure. The LARS score was categorized as minor LARS (21-29) and major LARS (30-42).

RESULTS

The proportions of patients with minor and major LARS were significantly larger and Wexner scores significantly higher in patients with distal tumors and a lower anastomosis level than in those with proximal tumors and a higher anastomosis level. Among the patients with lower rectal cancer, the proportions with minor and major LARS were similar between those with and without preoperative RT. The Wexner scores in patients with preoperative RT were significantly higher than in patients without RT. A distal tumor location and lower anastomosis level were independent risk factors of major LARS in multivariate analyses.

CONCLUSION

A distal tumor location, low anastomosis level, and preoperative RT might be associated with postoperative bowel dysfunction in rectal cancer patients.

Survival outcomes associated with Lynch syndrome colorectal cancer and metachronous rate after subtotal/total versus segmental colectomy: Meta-analysis

BACKGROUND

Lynch syndrome is associated with the most common form of heritable bowel cancer. There remains limited level 1 evidence on survival outcomes and rate of metachronous tumor associated with Lynch syndrome colorectal cancer.

METHODS

A systematic literature search of original studies was performed on Ovid searching MEDLINE, Embase, Cochrane Database of Systematic Reviews, American College of Physicians ACP Journal Club, Database of Abstracts of Reviews of Effects DARE, and Clinical Trials databases from inception of database to February 2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was followed. The data were pooled using a random-effects model. All of the P values were 2-tailed, and statistical analysis was performed using RevMan v. 5.3 Cochrane Collaboration.

RESULTS

From 1,942 studies, 15 studies met the inclusion criteria and were included for qualitative and quantitative synthesis. The five-year overall survival was 89.5% (82.0-94.1%), P < .01; I² = 89%. The ten-year overall survival was 80.5% (68.7-88.6%), P < .01; I² = 81%. The fifteen-year overall survival was 70% (33.7%-91.5%), P < .01; I² = 93%. Univariate meta-regression analysis showed no statistically significant difference in 5-year overall survival by sex, age, MLH1, MSH2, MSH6, nor tumor location (right versus left colon). The metachronous tumor rate was 12% to 33% with a follow-up period of up to 15 years, significantly lower in patients who underwent subtotal/total colectomy (0-6%).

CONCLUSION

The overall survival of patients with colorectal cancer with Lynch syndrome was approximately 90% at 5 years, 80% at 10 years, and 70% at 15 years. The metachronous tumor rate was approximately 10% to 30% at up to 15 years, significantly improved by subtotal/total colectomy.

A single centre audit: repeat pre-operative colonoscopy

BACKGROUND

Repeat colonoscopy may be required for tumour localisation. The aim of the study is to explore the clinical settings it was used and benchmark the quality of initial colonoscopy against standardized guidelines for tumour localisation, tattooing and colonoscopy reporting amongst clinicians.

METHODS

A retrospective study from 2016 to 2021 has been performed on patients who underwent elective colorectal cancer resections at the Northern Hospital. Patient demographics, colonoscopic and operative details were retrieved from the Bi-National Colorectal Cancer Audit (BCCA) Registry database and hospital medical records.

PRIMARY OUTCOMES

changes in operative approach and delays to operation.

SECONDARY OUTCOMES

reasons for a repeat colonoscopy and complications from repeat colonoscopy.

RESULTS

A total of 339 patients were included in this study. 94 (28.6%) underwent a repeat colonoscopy. Re-scoping rate was 29.6% for surgeons, and 26.2% for non-operating endoscopists. Surgeons had a 5.9% localisation error rate, and non-operating endoscopist 6.95% (p = 0.673). Surgeons did not have a lower rate of repeat colonoscopy (p = 0.462). Repeat endoscopy was associated with a longer time to definitive operation (p < 0.001). No complications were associated with a repeat colonoscopy.

CONCLUSION

There was no difference in localisation error rates or repeat colonoscopy amongst surgeons (29.6%) and non-operating endoscopists (26.2%) (p = 0.462). This could be explained by the standardized endoscopy training in Australia governed by a common training board. Lack of tattooing at index colonoscopy and inadequate documentation often led to a repeat endoscopy, which was associated with a longer time to definitive operation. Standardized guidelines in tattooing of lesions and colonoscopy reporting should be implemented.

What Is the Optimal Elective Colectomy for Splenic Flexure Cancer: End of the Debate? A Multicenter Study From the GRECCAR Group With a Propensity Score Analysis

BACKGROUND

The optimal elective colectomy in patients with splenic flexure tumor is debated.

OBJECTIVE

This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, histological, and survival outcomes in this setting.

DESIGN

This is a multicenter retrospective cohort study.

SETTING

Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included.

PATIENTS

Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers.

INTERVENTIONS

Propensity score weighting was performed to compare short- and long-term outcomes.

MAIN OUTCOME MEASURES

The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage.

RESULTS

The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p < 0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p < 0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p < 0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures.

LIMITATIONS

The study was limited by its retrospective design.

CONCLUSIONS

In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703.

CUL ES LA COLECTOMA ELECTIVA PTIMA PARA EL CNCER DE NGULO ESPLNICO FIN DEL DEBATE UN ESTUDIO MULTICNTRICO DEL GRUPO GRECCAR CON UN ANLISIS DE PUNTAJE DE PROPENSIN

ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p <0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min [120-460] frente a 180 min [68-440] frente a 217 min [149-480], p <0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días [5-56] frente a 10 [4-175] frente a 9 [4-55], p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 [8-90] frente a 15 [1-81] frente a 16 [3-52], p <0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.

Segmental resection of splenic flexure colon cancers provides an adequate lymph node harvest and is a safe operative approach - an analysis of the ACS-NSQIP database

Introduction

Fewer than 10% of colon cancers are found at the splenic flexure. A standard surgical approach to these cancers has not been defined. The goal of this study was to compare lymph node harvest and post-operative morbidity between segmental resection and formal left hemicolectomy for splenic flexure colon cancers.

Method

Patients diagnosed with a splenic flexure cancer were identified from the 2012–2018 ACS-NSQIP colectomy-targeted database. Patients were categorized based on type of surgical resection – left hemicolectomy with colorectal anastomosis or segmental colectomy with colocolonic anastomosis. Demographic, clinicopathologic, and post-operative outcomes were compared between groups. Factors independently associated with lymph node harvest, operative time, and post-operative morbidity were investigated by linear and binomial logistic regression models.

Results

A total of 3,049 patients underwent colectomy for a splenic flexure cancer. Of these, 83.6% had a segmental colectomy and 73% were performed by a minimally invasive approach. T- and N-stage did not differ between segmental and left hemicolectomy groups (p = 0.703 and p = 0.429, respectively). Inadequate nodal harvest (< 12 nodes) was infrequent and similar between the two procedures (7.4% vs. 9.1%, p = 0.13). Operative time was significantly shorter for segmental colectomy (213 ± 83.5 min vs. 193 ± 84.1 min, p < 0.0001) and major morbidity was similar between the two surgical techniques (8.4% vs. 8.9%, p = 0.75). After accounting for demographic, clinicopathologic, and operative factors, binomial logistic regression showed that type of procedure was not significantly associated with LN harvest (OR 0.80, 95%CI 0.54–1.17) or major morbidity (OR 1.17, 95%CI 0.36–3.81). However, on linear regression, segmental splenic flexure resection was associated with shorter operative time (estimate 20.29, 95%CI 12.61–27.97, p < 0.0001).

Conclusion

Splenic flexure resection for colon cancer is associated with an adequate lymph node harvest. Compared to a formal left hemicolectomy, a segmental resection also has a shorter operative time with equivalent post-operative morbidity.

Management of Dietary Habits and Diarrhea in Fap Individuals: A Mediterranean Low-Inflammatory Dietary Intervention

Background: A total colectomy and a frequent life-long endoscopic surveillance are guaranteed to patients with Familial Adenomatous Polyposis (FAP) to reduce their risk of duodenal and rectal stump cancers. However, after surgery, individuals with FAP suffer from an increased number of diarrheal discharges that force them to dietary restrictions. A non-randomized pilot study was conducted to assess whether a three-month low-inflammatory Mediterranean dietary intervention reduces gastro-intestinal markers of inflammation in FAP individuals. The aim of the present work is to evaluate the participant’s adherence to the proposed dietary recommendations and the change in their number of diarrheal discharges. Methods: 26 FAP individuals aged >18 years, who underwent a total colectomy with ileo-rectal anastomosis and were involved in the surveillance program at the Fondazione IRCCS Istituto Nazionale Tumori of Milan, were included in the present analysis. Results: FAP individuals significantly reduced the Not recommended foods (p-value: 0.002) and increased the consumption of the Recommended ones (p-value: 0.075). The adherence to the proposed dietary recommendations was accompanied by a significant decrease in the number of diarrheal discharges (p-value: 0.008). Conclusions: This study suggests that adhering to a low-inflammatory Mediterranean diet has a potential protective effect on the number of diarrheal discharges in FAP individuals.

Malignant Large Bowel Obstruction

Large bowel obstruction is a serious and potentially life-threatening surgical emergency which is associated with high morbidity and mortality rate. The most common etiology is colorectal cancer which accounts for over 60% of all large bowel obstructions. Proper assessment, thoughtful decision-making and prompt treatment is necessary to decrease the high morbidity and mortality which is associated with this entity. Knowledge of the key elements regarding the presentation of a patient with a large bowel obstruction will help the surgeon in formulating an appropriate treatment plan for the patient. Comprehensive knowledge and understanding of the various treatment options available is necessary when caring for these patients. This chapter will review the presentation of patients with malignant large bowel obstruction, discuss the various diagnostic modalities available, as well as discuss treatment options and the various clinical scenarios in which they are most appropriately utilized.

European guidelines from the EHTG and ESCP for Lynch syndrome: an updated third edition of the Mallorca guidelines based on gene and gender

BACKGROUND

Lynch syndrome is the most common genetic predisposition for hereditary cancer but remains underdiagnosed. Large prospective observational studies have recently increased understanding of the effectiveness of colonoscopic surveillance and the heterogeneity of cancer risk between genotypes. The need for gene- and gender-specific guidelines has been acknowledged.

METHODS

The European Hereditary Tumour Group (EHTG) and European Society of Coloproctology (ESCP) developed a multidisciplinary working group consisting of surgeons, clinical and molecular geneticists, pathologists, epidemiologists, gastroenterologists, and patient representation to conduct a graded evidence review. The previous Mallorca guideline format was used to revise the clinical guidance. Consensus for the guidance statements was acquired by three Delphi voting rounds.

RESULTS

Recommendations for clinical and molecular identification of Lynch syndrome, surgical and endoscopic management of Lynch syndrome-associated colorectal cancer, and preventive measures for cancer were produced. The emphasis was on surgical and gastroenterological aspects of the cancer spectrum. Manchester consensus guidelines for gynaecological management were endorsed. Executive and layperson summaries were provided.

CONCLUSION

The recommendations from the EHTG and ESCP for identification of patients with Lynch syndrome, colorectal surveillance, surgical management of colorectal cancer, lifestyle and chemoprevention in Lynch syndrome that reached a consensus (at least 80 per cent) are presented.

Laparoscopic retrojejunal trans-mesenteric anastomosis for extended left-sided colorectal resections - a new solution to an old problem

AIM

Following extended left-sided colorectal resection, creation of the anastomosis can be challenging due to insufficient length of the remaining proximal and distal bowel. Retroileal pull-through and the Deloyers procedure are feasible but require ligation of the middle colic vessels and additional right colonic mobilization. The aim of this study was to describe our initial experience with an alternative technique for performing tension-free anastomosis following minimally invasive left-sided resection.

METHOD

This was a retrospective case series of all patients who underwent a retrojejunal trans-mesenteric pull-through following elective laparoscopic left-sided colorectal surgery between September 2019 and September 2020. Placing the retrojejunal window 15-20 cm distal to the duodenojejunal junction allows the transverse colon to pass via the most direct route through the base of the proximal jejunal mesentery to the distal colon or rectal stump instead of passing over the small bowel, yielding additional length for the anastomosis. An accompanying video demonstrates this technique for three different case scenarios.

RESULTS

Seven consecutive patients underwent this approach following colorectal resection; three had inherently shorter left colons, two had synchronous left-sided tumours and two had inadvertent intraoperative marginal artery injury. There were no anastomotic complications or early postoperative morbidity related to the mesenteric window. The additional time taken for the procedure ranged from 5 to 35 min. The risk of complications related to extended left-sided resections may possibly be reduced, although further studies are required to evaluate this.

CONCLUSION

Retrojejunal trans-mesenteric pull-through is a novel, but straightforward, safe and useful option for reducing tension in laparoscopic left-sided colorectal anastomoses.

Unexplained anemia: A case report of metachronous adenocarcinoma arising in the transverse colon following right hemicolectomy for a primary cecal carcinoma

Metachronous colonic carcinomas arise from months to years after the resection of the first or index primary colorectal cancer. They are not a result of tumor recurrence or metastasis and likely arise as a result of the field cancerization effect. This report presents the case of a 63-year-old male patient without family history of a colorectal cancer but had an index primary adenocarcinoma of the cecum (stage IIIC) five years ago that was treated with surgical resection and adjuvant radiotherapy and chemotherapy. He presented with fatigue and anemia of 6-month duration secondary to recurrent melena, and the specific cause of which remained obscure despite intensive diagnostic workup. Recurrence of a malignancy at the previous anastomosis site was ruled out. The patient continued to have recurrent and intermittent gastrointestinal bleeding until a nuclear red blood cell scan detected a bleeding spot in the epigastric region, which actually turned out to be a second primary carcinoma (stage I) arising from an adenoma in the transverse colon. The patient underwent a left colectomy with ileosigmoid anastomosis formation. During a two-month postoperative follow-up, the patient did not experience any episode of melena or anemia. Even though metachronous colon cancers rarely present with a recurrent and intermittent gastrointestinal bleeding with melena, an aggressive workup must be aimed at ruling out a second independent malignancy in patients who are in remission after an index primary colorectal cancer resection through hemicolectomy. Any neoteric lesion found on colonoscopy in such cases should be dealt with a higher degree of suspicion. Therefore, the need for surveillance colonoscopy as recommended by the National Comprehensive Cancer Network guidelines is imperative and should be practiced in resource-limited countries.

A 10-Year Evaluation of Short-Term Outcomes After Synchronous Colorectal Cancer Surgery: a Dutch Population-Based Study

BACKGROUND

Synchronous colorectal cancer (CRC) has been associated with higher postoperative morbidity and mortality rates compared to solitary CRC. The influence of improved CRC care and introduction of screening on these outcomes remains unknown. This study aimed to evaluate time trends in incidence, population characteristics, and short-term outcomes of synchronous CRC patients at the population level over a 10-year time period.

METHODS

Data of all patients that underwent resection for primary CRC were extracted from the Dutch ColoRectal Audit (2010-2019). Analyses were stratified for solitary and synchronous colon and rectal cancer. Multilevel logistic regression analyses were used to determine factors associated with pathological and surgical outcomes.

RESULTS

Among 100,474 patients, 3.1% underwent surgery for synchronous CRC. A screening-related decrease for surgically treated left-sided solitary and synchronous colon cancer and a temporary increase for exclusively right-sided colon cancer were observed. Synchronous CRC patients had higher rates of complicated postoperative course, failure to rescue, and mortality. Bilateral synchronous colon cancer was more often treated with subtotal colectomy (25.4%) and demonstrated higher rates of surgical complications, reinterventions, prolonged hospital stay, and mortality than other synchronous tumor locations.

DISCUSSION

National bowel screening resulted in contradictory effects on surgical resections for synchronous CRCs depending on sidedness. Bilateral synchronous colon cancer required more often extended resection resulting in significantly worse outcomes than other synchronous tumor locations. Identification of low volume, high complex CRC subpopulations is relevant for individualized care and has implications for case-mix correction and benchmarking in clinical auditing.

Impact of routine mismatch repair screening on genetic counseling and surgical management in colorectal cancer patients

BACKGROUND

Mismatch repair (MMR) deficiency in colorectal cancer (CRC) should prompt consideration of genetic counseling (GC) as a Lynch syndrome (LS) diagnosis may have several implications for the patient and family. The study aims were to examine how routine MMR testing influences the rate of GC and surgical resection extent.

METHODS

A single-institution retrospective review was performed on CRC specimens (including colonoscopic biopsies) routinely screened for MMR deficiency from 2012 to 2018. MLH1-deficient cancers with mutated BRAF or MLH1-promoter hypermethylation were excluded.

RESULTS

MMR deficiency was identified in 295 of 1139 CRC specimens. After exclusions, 57 patients remained. Forty-two patients (74%) were identified preoperatively, and 35 (83%) were referred to GC: 16 were seen preoperatively, 9 postoperatively. Eight patients were diagnosed with Lynch syndrome (LS) preoperatively: 2 had no resection, 2 underwent segmental resection and 4 underwent extended resection.

CONCLUSIONS

Most MMR-deficient patients were identified and referred to GC preoperatively, though not all were seen. Of the preoperatively diagnosed LS patients, half underwent extended resection. Barriers to GC and decision-making around resection extent bears further study.

Does Bowel Function Change After Colectomy for Colon Malignancy?

BACKGROUND

Colon cancer patients often ask how surgery will affect bowel function. Current understanding is informed by conflicting data, making preoperative patient counseling difficult. We aimed to evaluate patient-reported bowel function changes after colectomy for colon malignancy.

MATERIAL AND METHODS

This was a retrospective analysis of a prospectively collected institutional database from July 2015 to June 2019. The included patients underwent colectomy for adenocarcinoma of the colon, and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation and postoperative followup. Preoperative and postoperative scores were compared using paired t-tests. Multivariable analysis was performed using domains demonstrating statistical significance on bivariate analysis, assessing the factors that were associated with symptomatic bowel function.

RESULTS

We identified 117 patients with a mean age of 64 ± 13 y. The median time between preoperative and postoperative questionnaire completion was 52 d (interquartile range 45-70). Bowel movement frequency increased significantly from a mean preoperative score of 9.72 to a mean postoperative score of 14.2 (P = 0.003). There were no significant differences in the remaining four domains of bowel function or global function. Multivariable analysis demonstrated higher likelihood of symptomatic postoperative frequency scores in male patients (OR 3.85, 95% CI 1.44-11.11, P = 0.007) and patients with symptomatic preoperative frequency (OR 5.56, 95% CI 1.62-19.02, P = 0.006).

CONCLUSIONS

Patient-reported bowel movement frequency worsens at postoperative follow-up after colectomy for colon cancer, while overall bowel function does not change. Men and patients with preoperative symptomatic frequency have an increased likelihood of reporting symptomatic postoperative frequency. These findings should guide more personalized and evidence-based preoperative patient counseling.

Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association

AIM

It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies.

METHOD

From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively.

RESULTS

In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups.

CONCLUSION

The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

Colorectal anastomosis after laparoscopic extended left colectomy: techniques and outcome

AIM

After extended left colectomy, traditional colorectal anastomosis is often not feasible because of insufficient length of the remaining colon to perform a tension-free anastomosis. Total colectomy with ileorectal anastomosis could be an alternative but this can lead to unsatisfactory quality of life. Trans-mesenteric colorectal anastomosis or inverted right colonic transposition (the so-called Deloyers procedure) are two possible solutions for creating a tension-free colorectal anastomosis after extended left colectomy. Few studies have reported their results of these two techniques and mostly via laparotomy. The aim of this study was to describe the trans-mesenteric colorectal anastomosis and the inverted right colonic transposition procedure via a laparoscopic approach and report the outcome in a series of 13 consecutive patients.

METHOD

This was retrospective chart review of laparoscopic colorectal surgery with trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure from January 2015 up to 2019. An accompanying video demonstrates these two techniques.

RESULTS

Thirteen consecutive patients underwent either a laparoscopic trans-mesenteric colorectal anastomosis (n = 9) or an inverted right colonic transposition procedure (n = 4). One patient had intra-operative presacral bleeding that was stopped successfully without conversion. Two patients had a postoperative intra-abdominal abscess, but no anastomotic complications were recorded. The median number of bowel movements per day after 6 months was 2 (range 2-5).

CONCLUSIONS

Trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure is feasible laparoscopically. The now well-established classical advantages of the laparoscopic approach are associated with good functional outcome after these procedures.

Safety and efficacy of laparoscopic near-total colectomy and ileo-distal sigmoid anastomosis as a modification of total colectomy and ileorectal anastomosis for prophylactic surgery in patients with adenomatous polyposis syndromes: a comparative study

AIM

Colectomy in patients with adenomatous polyposis (AP) syndromes demands good oncological and surgical outcome. Total colectomy with ileorectal anastomosis (TC-IRA) is one surgical option for these patients. Anastomotic leakage rates of 11% have been reported following TC-IRA. Ileo-distal sigmoid anastomosis (IDSA) is a recent modification of our practice. Our aim was to compare postoperative outcome in patients with AP following near-total colectomy with IDSA (NT-IDSA) and TC-IRA at a single institution.

METHOD

A prospectively maintained database was reviewed to identify patients with AP who underwent laparoscopic NT-IDSA and TC-IRA. Patient demographics, early morbidity and mortality and outcome of endoscopic surveillance were evaluated.

RESULTS

A total of 191 patients with AP underwent laparoscopic colectomy between 2006 and 2017, of whom 139 (72.8%) underwent TC-IRA and 52 (27.2%) NT-IDSA. The median age at surgery in the TC-IRA and NT-IDSA groups was 20 years (IQR 17-45) and 27 years (IQR 19-50), respectively. Grade II complications were comparable between the two groups. There were no anastomotic leakages in the NT-IDSA group compared with 15 (10.8%) in the TC-IRA group (P = 0.0125) and no reoperation in the NT-IDSA group compared with 17 (12.2%) in the TC-IRA group (P = 0.008). The frequency of polypectomies per flexible sigmoidoscopy was comparable between the two groups.

CONCLUSION

This study demonstrates that laparoscopic NT-IDSA for polyposis is associated with a significant improvement in anastomotic leakage rates and surgical outcome. It is too soon to tell whether NT-IDSA alters the need for further intervention, either endoscopic polypectomy or further surgery.

Analysis of metachronous colorectal neoplasms and survival following segmental or extended resection in patients with hereditary non-polyposis colorectal cancer

PURPOSE

The high incidence of metachronous colorectal tumours in patients with hereditary non-polyposis colorectal cancer (HNPCC) encourages extended resection (ER); however, the optimal surgical approach remains unclear. We evaluated the incidences of metachronous colorectal neoplasms following curative colorectal cancer segmental resection (SR) vs ER in patients with HNPCC and investigated patients' oncologic outcomes according to surgical modality and mismatch repair status.

METHODS

We retrospectively investigated medical records of patients with HNPCC (per the Amsterdam II criteria) treated for primary colon cancer at our institution between 2001 and 2017. All patients underwent intensive endoscopic surveillance.

RESULTS

We included 87 patients (36 who underwent SR and 51 who underwent ER). The cumulative incidence of metachronous adenoma was higher in the SR group. One patient in the SR group (2.8%) and 3 in the ER group (5.9%) developed metachronous colon cancer; the difference was not significant (P = 0.693). Four patients in the SR group (11.1%) and 1 in the ER group (2.0%) developed distant recurrences; again, the difference was not significant (P = 0.155). Moreover, no significant differences were observed in the 5-year overall survival rates of patients in the SR and ER groups (88.2% vs 95.5%, P = 0.446); the same was true for 5-year disease-free survival rates (79.5% vs 91.0%, P = 0.147).

CONCLUSION

The incidence of metachronous cancer was not significantly different between the ER and SR groups; however, that of cumulative metachronous adenoma was higher in the SR group. Hence, intensive surveillance colonoscopy may be sufficient for patients with HNPCC after non-extensive colon resection.

Analysis of morbidity and mortality, quality of life and bowel function after total colectomy with ileorectal anastomosis versus right and left hemicolectomy: A study to optimise the treatment of lynch syndrome and attenuated polyposis coli

BACKGROUND

The optimal surgical treatment for colonic colorectal carcinoma (CRC) in Lynch Syndrome (LS) and attenuated polyposis coli (A-FAP phenotype) patients is still debated, since there is a high risk of metachronous colonic adenomas and carcinoma after primary surgery. The aim of this study was to compare surgical outcome, functional data, and Quality of Life (QoL) after total colectomy with ileorectal anastomosis (TC-IRA) compared to right (RH) or left hemicolectomy/sigmoidectomy (LH/SI).

METHODS

Patients who underwent TC-IRA (ileorectal anastomosis from 8 to 15 cm from the anal verge) for CRC and/or polyposis at our Surgical Department between 2001 and 2017 were included in the study group, and were matched one-to-one by baseline and clinical characteristics with a control group of RH and LH/SI. Morbidity and mortality data were collected (Clavien-Dindo classification). International validated questionnaires were used to investigate QoL and bowel function.

RESULTS

Fifty-five patients were enrolled in each group. No differences were found on length of hospital stay, Clavien-Dindo grade III-IV complications and mortality (p > 0.05). TC-IRA showed a longer operative time than RH and LH/SI (p < 0.0001) and a major blood loss than RH (p < 0.0001). Worse bowel function and worse QoL, only for the bowel-related items, were recorded in TC-IRA group. The general QoL was similar among the groups.

CONCLUSIONS

TC-IRA and segmental resection have similar morbidity and mortality. The worse bowel function in TC-IRA group does not impact on the general QoL. These data can be useful in the setting of risk-reducing surgery decision in LS and A-FAP patients.

Therapeutic effects of vitamin D on acetic acid-induced colitis in rats

PURPOSE

To analyze the effect of calcitriol treatment on acute colitis in an experimental rat model.

METHODS

A total of 24 adult Sprague Dawley albino rats were randomly separated into 3 equal groups: control group (n:8), colitis group (n:8), calcitriol administered group (n:8). A single dose of acetic acid (1 ml of 4% solution) was administered intrarectally to induce colitis. Group 1 was given 1 ml/kg 0.9% NaCl intraperitoneally; rats belonging to Group 2 were administered calcitriol 1 µg/kg for 5 days.

RESULTS

Plasma tumor necrosis factor alpha, Pentraxin 3, and malondialdehyde levels were significantly lower in the calcitriol administered colitis group than in the standard colitis group (p<0.01). In the Calcitriol group, there was a significant histological improvement in hyperemia, hemorrhage and necrotic areas in the epithelium compared to the placebo group (p <0.000).

CONCLUSION

The findings suggest that calcitriol may be an agent that could be used in acute colitis treatment.

What Factors Are Associated With the Eventual Need for an Ileostomy After Total Abdominal Colectomy and Ileosigmoid or Ileorectal Anastomosis for Crohn's Colitis in the Biologic Era?

BACKGROUND

Outcomes after total abdominal colectomy with ileosigmoid or ileorectal anastomosis for Crohn's colitis and risk factors for requirement of a permanent ileostomy remain poorly understood, particularly in the biologic era.

OBJECTIVE

This study aimed to determine long-term ostomy-free survival after ileosigmoid or ileorectal anastomosis for Crohn's colitis and potential risk factors for requirement of an ileostomy.

DESIGN

This is a retrospective cohort study.

SETTING

This study was conducted at a single-institution IBD tertiary referral center.

PATIENTS

Patients diagnosed with Crohn's disease and undergoing ileosigmoid or ileorectal anastomosis between 2006 and 2018 were selected.

MAIN OUTCOME MEASURE

Long-term ostomy-free survival and hazard ratios of potential predictors of ileostomy requirement were the primary outcomes measured.

RESULTS

One hundred nine patients (56% female) underwent ileosigmoid or ileorectal anastomosis for Crohn's disease. The majority of surgical procedures were completed in 2 or 3 stages (53%). The indication for total abdominal colectomy was predominantly medically refractory disease (77%), with dysplasia the second leading indication (13%). At an overall mean follow-up of 3 years, 16 patients had undergone either proctectomy or diversion with the rectum in situ. This resulted in ostomy-free survival estimates at 5 and 10 years of 78% (95% CI, 68-90) and 58% (95% CI, 35-94). A positive distal microscopic margin was the only risk factor for later requirement of a permanent ileostomy (HR, 5.4; 95% CI, 1.7-17.2).

LIMITATIONS

This study is limited because it is a retrospective study at a tertiary referral center.

CONCLUSIONS

Long-term ostomy-free survival can be achieved in the majority of patients who undergo restoration of intestinal continuity after total abdominal colectomy for Crohn's colitis. A positive distal microscopic margin was independently associated with long-term anastomotic failure, and it should be accounted for when risk stratifying patients for postoperative prophylactic medical therapy. See Video Abstract at http://links.lww.com/DCR/B111. ¿QUÉ FACTORES ESTÁN ASOCIADOS CON LA EVENTUAL NECESIDAD DE UNA ILEOSTOMÍA DESPUÉS DE UNA COLECTOMÍA ABDOMINAL TOTAL Y UNA ANASTOMOSIS ILEOSIGMOIDEA O ILEORRECTAL PARA LA COLITIS DE CROHN EN LA ERA BIOLÓGICA?: Los resultados después de la colectomía abdominal total con anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo para el requerimiento de una ileostomía permanente siguen siendo poco conocidos, particularmente en la era biológica.Determinar la supervivencia a largo plazo sin ostomía después de una anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo potenciales para la necesidad de una ileostomía.Estudio de cohorte retrospectivo.Centro de referencia de tercel nivel para enfermedad inflamatoria intestinal de una sola institución.Pacientes diagnosticados con enfermedad de Crohn y sometidos a anastomosis ileosigmoidea o ileorrectal entre 2006 y 2018Supervivencia a largo plazo sin ostomías y cocientes de riesgo de predictores potenciales de requerimiento de ileostomía109 pacientes (56% mujeres) se sometieron a anastomosis ileosigmoidea o ileorrectal por enfermedad de Crohn. La mayoría de los procedimientos quirúrgicos se completaron en 2 o 3 etapas (53%). La indicación de colectomía abdominal total fue predominantemente enfermedad médicamente refractaria (77%), con displasia la segunda indicación principal (13%). En un seguimiento medio general de 3 años, 16 pacientes se habían sometido a una proctectomía o a una derivación con el recto in situ. Esto dio como resultado estimaciones de supervivencia sin ostomía a los 5 y 10 años de 78% (intervalo de confianza del 95%: 68-90) y 58% (intervalo de confianza del 95%: 35-94), respectivamente. Un margen microscópico distal positivo fue el único factor de riesgo para el requerimiento posterior de una ileostomía permanente (razón de riesgo: 5.4; intervalo de confianza del 95%, 1.7-17.2).Estudio retrospectivo en un centro de referencia de tercer nivel.La supervivencia a largo plazo sin ostomía se puede lograr en la mayoría de los pacientes que se someten a la restauración de la continuidad intestinal después de la colectomía abdominal total por colitis de Crohn. Un margen microscópico distal positivo se asoció de forma independiente con la insuficiencia anastomótica a largo plazo, y debe tenerse en cuenta cuando se trata de pacientes con estratificación de riesgo para el tratamiento médico profiláctico postoperatorio. Consulte Video Resumen en http://links.lww.com/DCR/B111.