Laparoscopic colorectal surgery and discharge within 24 h-who is at risk for readmission?

AIM

The aim was to describe risk factors for hospital readmission in patients undergoing laparoscopic colorectal procedures and being discharged in ≤24 h.

METHOD

All consecutive patients undergoing minimally invasive colorectal surgery between 2010 and 2019 from a single institution were retrospectively reviewed. All patients were included in an enhanced recovery programme. Patients who met criteria for hospital discharge were compared according to the need for readmission in a 45-day follow-up.

RESULTS

In all, 664 patients underwent minimally invasive colorectal surgery during the study period and 237 (35.7%) were discharged in ≤24 h. Readmission was required in 16 (6.8%) patients discharged in ≤24 h and no postoperative mortality was observed in this group. Patients discharged in ≤24 h were more likely to have benign disease (P < 0.001), fewer associated procedures (P < 0.025) and intracorporeal anastomoses (P < 0.001). The type of surgical procedure (abdominoperineal resection), low rectal tumour, malignant disease, older age and longer operating time were associated with readmission. Age (OR 1.06; P = 0.037), malignant disease (OR 4.39; P = 0.05) and operating time (OR 1.03; P < 0.001) were identified as independent predictive factors for readmission amongst patients being discharged in ≤24 h.

CONCLUSION

Highly selected patients undergoing minimally invasive procedures in colorectal surgery may be safely discharged within 24 h following the procedure. High-risk features for readmission include older age, malignant disease and longer operating time.

Assessment of the non-surgical treatment of patients with rectal cancer who underwent neoadjuvant treatment with chemotherapy and radiotherapy at the oncology department

Objective To describe the partial results of a study in patients with rectal cancer who underwent neoadjuvant treatment with chemotherapy and radiotherapy regarding the rate of complete clinical response, disease-free survival, anorectal function, and quality of life.

Material and methods This was a prospective study from June 2015 to June 2018, in patients with low- or mid-rectum adenocarcinoma and clinical stage II or III, treated with radiotherapy and chemotherapy (IMRT 54 Gy for six weeks) concomitant with 5-fluorouracil (5-FU) 380 mg/m2 and folinic acid (LV) 20 mg/m2 for five days in the first and fifth weeks and two cycles after radiotherapy (5-FU 400 mg/m2 and LV 20 mg/m2) every 28 days. After the treatment, clinical examination, rectosigmoidoscopy, pelvic magnetic resonance imaging, chest and upper abdomen computed tomography, and CEA testing were performed. Resection surgery was performed in those with incomplete clinical response (iCR). Those with complete clinical response (cCR) are under observation (wait-and-see policy). Manometry and scintigraphic function and quality of life scales were collected before treatment and at 30 and 90 days after the end of treatment.

Results As of June 2018, 11 patients were recruited. One was excluded from the analysis for presenting severe toxicity, suggestive of dihydropyrimidine dehydrogenase (DPD) deficiency, after the first chemotherapy cycle. All others completed the treatment. Two patients presented toxicity grade 3/4 related to chemotherapy and had their doses reduced. Seven patients (70%) presented iRC; three underwent rectosigmoidectomy, and the anatomopathological evaluation indicated complete pathological response in two cases (28.5%). Three (30%) presented cCR and did not present evidence of disease after a mean follow-up of 19 months. Patients presented improvement of anorectal function and quality of life.

Conclusions Advances in the neoadjuvant treatment of rectal tumors contributed to better rates of complete pathological responses. New paradigms promote an increase in the complete clinical response rates, which would allow organ preservation and consequent reduction of surgical morbidity.

Transanal minimally-invasive surgery (TAMIS): Technique and results from an initial experience

Transanal endoscopic microsurgery is a minimally-invasive approach for rectal lesions. Superior exposure and access to the entire rectum result in lesser risk of compromised margins and lower recurrence rates, when compared to conventional transanal excision. The aim of this study was to describe a single institution's initial experience with transanal minimally invasive surgery (TAMIS). This was a prospective review of our database. Eleven procedures from January 2012 to June 2013 were analyzed.

Results eleven operations were completed. Five men were evaluated. Mean age was 62.9 (40-86). Mean follow-up was 9.3 (2-17) months. Average tumor size was 3.8 (1.8-8) cm. Mean distance from anal verge was 6.3 (3-12) cm. Mean operating time was 53.73 (28-118) min. Postoperative complication rate was 9.1%. There were no readmissions. Mortality was null. Operative pathology disclosed the presence of adenoma in four patients, invasive adenocarcinoma in two, neuroendocrine carcinoma in three, and no residual lesion in one case. TAMIS is a minimallyinvasive procedure with low postoperative morbidity at the initial experience. TAMIS is a curative procedure for benign lesions and for selected early cancers. It is useful after neoadjuvant therapy for strictly selected cancers, pending the results of multi-institutional trials.

BRAZILIAN AND ARGENTINEAN MULTICENTRIC STUDY IN THE SURGICAL MINIMALLY INVASIVE TREATMENT OF PILONIDAL CYST

Background:

The pilonidal cyst is an infection of the skin and the subcutaneous tissue, secondary to a chronic inflammation with a greater frequency in the sacrococcygeal region, and associated to the presence of hair. The treatment is eminently surgical.

Aim:

To demonstrate the endoscopic treatment of pilonidal cyst.

Method:

Prospective study with 67 patients who had as surgical indication the diagnosis of pilonidal cyst. They were submitted to a surgical procedure from June 2014 to March 2018. The equipment used was the Meinero fistuloscope, a shutter, a monopolar electrode, a brush and endoscopic forceps.

Results:

Of the 67 patients, 67% (n=45) were male and 33% (n=22) female, with a mean age of 25 years (17-45). Surgical time in average was 40 min (20-120) and mean healing time of four weeks (3-12). Surgical complications were presented in 7% cases (n=5) and recurrences in 9% (n=6).

Conclusion:

The endoscopic treatment of the pilonidal cyst is feasible and presents good surgical results.

Transanal minimally invasive surgery for total mesorectal excision (ETM) through transanal approach (TaETM) with robotic and Transanal Endoscopic Operations (TEO) combined access: step by step surgery

Rational

In the treatment of colorectal cancer, from 1982 Heald proposed standardization of the total mesorectal excision, with a significant reduction in the recurrence rate. But the treatment of lower rectal lesions is still a challenge.

Aim

To describe the association of robotic low anterior resection- TATA (Transanal Abdominal Transanal Resection), with transanal access using Transanal Endoscopic Operations - TEO in the treatment of lower rectal cancer.

Method

The TATA performs robotic abdominal approach and the TEO performs the perineal approach, developing total mesorectal excision (TME) transanally (TaETM).

Result

The TaETM technique was applied in a woman with rectal adenocarcinoma 5 cm from the anal verge that had been submitted to chemoradiation. The procedure was performed with satisfatory operative time and favorable oncological outcome (grade 3 mesorectal excision).

Conclusion

This is a promising minimally invasive procedure in the armamentarium of rectal cancer treatment, specially in challenging scenarios such as narrow pelvis, obesity and very low rectal tumors.

Video-assisted anal fistula treatment: technical considerations and preliminary results of the first Brazilian experience

BACKGROUND

Anorectal fistula represents an epithelized communication path of infectious origin between the rectum or anal canal and the perianal region. The association of endoscopic surgery with the minimally invasive approach led to the development of the video-assisted anal fistula treatment.

AIM

To describe the technique and initial experience with the technique video-assisted for anal fistula treatment.

TECHNIQUE

A Karl Storz video equipment was used. Main steps included the visualization of the fistula tract using the fistuloscope, the correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening which can be accomplished through firing a stapler, cutaneous-mucosal flap, or direct closure using suture.

RESULTS

The mean distance between the anal verge and the external anal orifice was 5.5 cm. Mean operative time was 31.75 min. In all cases, the internal fistula opening could be identified after complete fistuloscopy. In all cases, internal fistula opening was closed using full-thickness suture. There were no intraoperative or postoperative complications. After a 5-month follow-up, recurrence was observed in one (12.5%) patient.

CONCLUSION

Video-assisted anal fistula treatment is feasible, reproducible, and safe. It enables direct visualization of the fistula tract, internal opening and secondary paths.