Optimizing omentoplasty for management of chronic pelvic sepsis by intra-operative fluorescence angiography: a comparative cohort study

Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre

AIM

Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre.

METHOD

Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome.

RESULTS

In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567).

CONCLUSION

High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.

Omentoplasty in Patients Undergoing Abdominoperineal Resection After Long-Course Chemoradiation for Locally Advanced and Locally Recurrent Rectal Cancer: A Comparative Single-Institution Cohort Study

BACKGROUND

Omentoplasty is a commonly performed procedure after abdominoperineal resection for rectal cancer, but its effectiveness to reduce pelviperineal complications is not firmly established.

OBJECTIVE

This study aimed to assess the impact of omentoplasty on postoperative outcomes after long-course (chemo) radiotherapy and abdominoperineal resection in patients with locally advanced and locally recurrent rectal cancer.

DESIGN

Retrospective cohort study.

SETTINGS

Single center.

PATIENTS

All patients with locally advanced and locally recurrent rectal cancer undergoing abdominoperineal resection after neoadjuvant (chemo)radiation in a tertiary referral center between 2008 and 2020 were retrospectively reviewed.

MAIN OUTCOME MEASURES

Multivariable logistic and linear regression analyses were performed to analyze the association between omentoplasty and pelviperineal complications, duration of nasogastric tube drainage, and length of hospital stay.

RESULTS

A total of 305 patients were analyzed, of whom 245 underwent omentoplasty (80%). Pelviperineal complications occurred in 151 patients (50%) overall, in 125 patients (51%) with omentoplasty, and in 26 patients (43%) without omentoplasty. Independent predictors of pelviperineal complications in multivariable analyses were smoking (OR 2.68; 95% CI, 1.46-4.94) and high BMI (OR 1.68; 95% CI, 1.00-2.83), but not omentoplasty (OR 1.36; 95% CI, 0.77-2.40). The mean duration of nasogastric tube drainage was longer after omentoplasty (6 vs 4 d) with a significant association in multivariable analysis (β coefficient 1.97; 95% CI, 0.35-3.59). Patients undergoing omentoplasty had a significantly longer hospital stay (14 vs 10 d), and omentoplasty remained associated with a prolonged hospital stay after adjusting for confounding (β coefficient 3.05; 95% CI, 0.05-5.74).

LIMITATIONS

Retrospective design.

CONCLUSION

Omentoplasty was not associated with a reduced risk of the occurrence of short-term pelviperineal complications after abdominoperineal resection in patients undergoing long-course (chemo)radiotherapy. Furthermore, in patients undergoing omentoplasty, prolonged duration of nasogastric tube drainage and hospital stay was observed. See Video Abstract at http://links.lww.com/DCR/C124 .

OMENTOPLASTIA EN PACIENTES SOMETIDOS A RESECCIN ABDOMINOPERINEAL DESPUS DE QUIMIORRADIOTERAPIA DE CURSO LARGO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO Y LOCALMENTE RECURRENTE ESTUDIO DE COHORTE COMPARATIVO DE UNA SOLA INSTITUCIN

ANTECEDENTES:La omentoplastía es un procedimiento que se realiza comúnmente después de la resección abdominoperineal por cáncer de recto, pero su efectividad para reducir las complicaciones pelvicoperineales no está firmemente establecida.OBJETIVO:Evaluar el impacto de la omentoplastía en las complicaciones pelvicoperineales a corto plazo y los resultados postoperatorios después quimioradioterapia de curso largo y resección abdominoperineal en pacientes con cáncer de recto localmente avanzado y localmente recurrente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Centro único.PACIENTES:Se revisaron retrospectivamente todos los pacientes con cáncer de recto localmente avanzado y localmente recurrente sometidos a resección abdominoperineal después de quimioradiación neoadyuvante en un centro de referencia de tercer nivel entre 2008 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis de regresión lineal y logística multivariable para examinar la asociación entre la omentoplastía y las complicaciones pelvicoperineales (p. ej., problemas de heridas perineales y abscesos pélvicos), la duración del drenaje por sonda nasogástrica y la duración de la estancia hospitalaria.RESULTADOS:Se analizaron un total de 305 pacientes de los cuales 245 fueron sometidos a omentoplastía (80%). Las complicaciones pelvicoperineales ocurrieron en 151 pacientes (50%) en general, y en 125 (51%) y 26 (43%) de los pacientes con o sin omentoplastía, respectivamente. Los predictores independientes de complicaciones pelvicoperineales en análisis multivariable fueron el tabaquismo (OR 2.68, IC del 95% 1.46 a 4.94) y un IMC alto (OR 1.68, IC del 95% 1.00 a 2.83), pero no la omentoplastía (OR 1.36, IC del 95% 0.77 a 2.40) . La duración media del drenaje por sonda nasogástrica fue mayor después de la omentoplastía (6 frente a 4 días) con una asociación significativa en el análisis multivariable (coeficiente β 1.97, IC del 95%: 0.35-3.59). Los pacientes que se sometieron a una omentoplastía tuvieron una estancia hospitalaria significativamente más larga (14 frente a 10 días), y la omentoplastía permaneció asociada con una estancia hospitalaria prolongada después de ajustar por factores de confusión (coeficiente β 3.05, IC del 95%: 0.05-5.74).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:La omentoplastía no se asoció con un riesgo reducido de aparición de complicaciones pelvicoperineales a corto plazo después de la resección abdominoperineal en pacientes sometidos a quimioradioterapia de larga duración. Adicionalmente, en los pacientes sometidos a omentoplastía se observó una duración prolongada del drenaje por sonda nasogástrica y la estancia hospitalaria. Consulte Video Resumen en http://links.lww.com/DCR/C124 . (Traducción-Dr. Jorge Silva Velazco ).

Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery

BACKGROUND

Indocyanine green (ICG) imaging has been increasingly used for intraoperative guidance in colorectal surgery over the past decade. The aim of this study was to review and organize, according to different type of use, all available literature on ICG guided colorectal surgery and highlight areas in need of further research and discuss future perspectives.

METHODS

PubMed, Scopus, and Google Scholar databases were searched systematically through November 2022 for all available studies on fluorescence-guided surgery in colorectal surgery.

RESULTS

Available studies described ICG use in colorectal surgery for perfusion assessment, ureteral and urethral assessment, lymphatic mapping, and hepatic and peritoneal metastases assessment. Although the level of evidence is low, results are promising, especially in the role of ICG in reducing anastomotic leaks.

CONCLUSIONS

ICG imaging is a safe and relatively cheap imaging modality in colorectal surgery, especially for perfusion assessment. Work is underway regarding its use in lymphatic mapping, ureter identification, and the assessment of intraperitoneal metastatic disease.

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art

Indocyanine green (ICG) fluorescence imaging is widely used in abdominal surgery. The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems. In that setting, ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow. The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery. Each type of use has been separately addressed and the evidence was investigated. During rectal resection, ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks. In addition, ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury. This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed. This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature. Although further studies are need to investigate the real clinical benefits, these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.

Fluorescence-guided surgery in colorectal cancer; A review on clinical results and future perspectives

BACKGROUND

Colorectal cancer is the fourth most diagnosed malignancy worldwide and surgery is one of the cornerstones of the treatment strategy. Near-infrared (NIR) fluorescence imaging is a new and upcoming technique, which uses an NIR fluorescent agent combined with a specialised camera that can detect light in the NIR range. It aims for more precise surgery with improved oncological outcomes and a reduction in complications by improving discrimination between different structures.

METHODS

A systematic search was conducted in the Embase, Medline and Cochrane databases with search terms corresponding to 'fluorescence-guided surgery', 'colorectal surgery', and 'colorectal cancer' to identify all relevant trials.

RESULTS

The following clinical applications of fluorescence guided surgery for colorectal cancer were identified and discussed: (1) tumour imaging, (2) sentinel lymph node imaging, (3) imaging of distant metastases, (4) imaging of vital structures, (5) imaging of perfusion. Both experimental and FDA/EMA approved fluorescent agents are debated. Furthermore, promising future modalities are discussed.

CONCLUSION

Fluorescence-guided surgery for colorectal cancer is a rapidly evolving field. The first studies show additional value of this technique regarding change in surgical management. Future trials should focus on patient related outcomes such as complication rates, disease free survival, and overall survival.