Laparoscopic and robotic intracorporeal resection and end-to-end anastomosis in left colectomy: a prospective cohort study - stage 2a IDEAL framework for evaluating surgical innovation

PURPOSE

To analyze the safety and feasibility of intracorporeal resection and anastomosis in upper rectum, sigmoid, and left colon surgery, via both laparoscopic and robotic approaches. The secondary aim was to assess possible short-term differences between laparoscopic versus robotic surgery.

METHODS

A prospective observational cohort study according to IDEAL framework exploration and assessment stage (Development, stage 2a), evaluating and comparing the laparoscopic approach and the robotic approach in left colon, sigmoid, and upper rectum surgery with intracorporeal resection and end-to-end anastomosis. Demographic, preoperative, surgical, and postoperative variables of patients undergoing laparoscopic and robotic surgery are described and compared according to the surgical technique used.

RESULTS

Between May 2020 and March 2022, seventy-nine patients were consecutively included in the study, 41 operated via laparoscopy (laparoscopic left colectomy: LLC) and 38 by robotic surgery (robotic left colectomy: RLC). There were no statistically significant differences between the two groups in terms of demographic variables. In surgical variables, the median surgical times differed significantly: 198 min (SD 48 min) for LLC vs. 246 min (SD 72 min) for RLC (p = 0.01, 95% CI: - 75.2 to - 20.5)). The only significant difference regarding postoperative complications was a higher degree of relevant morbidity in the LLC (Clavien-Dindo > II (14.6% vs. 0%, p = 0.03) and Comprehensive Complication Index (IQR 22 vs. IQR 0, p = 0.03). The pathological results were similar in both approaches.

CONCLUSION

Laparoscopic and robotic intracorporeal resection and anastomosis are feasible and safe, and obtain similar surgical, postoperative, and pathological results than described in literature. However, morbidity seems to be higher in LLC group with fewer relevant postoperative complications. The results of this study enable us to proceed to stage 2b of the IDEAL framework.

CLINICAL TRIAL REGISTRATIONS

The study is registered in Clinical trials with the registration code NCT0445693.

Alterations in tissue oxygen saturation measured by near-infrared spectroscopy in trauma patients after initial resuscitation are associated with occult shock

PURPOSE

Persistent occult hypoperfusion after initial resuscitation is strongly associated with increased morbidity and mortality after severe trauma. The objective of this study was to analyze regional tissue oxygenation, along with other global markers, as potential detectors of occult shock in otherwise hemodynamically stable trauma patients.

METHODS

Trauma patients undergoing active resuscitation were evaluated 8 h after hospital admission with the measurement of several global and local hemodynamic/metabolic parameters. Apparently hemodynamically stable (AHD) patients, defined as having SBP ≥ 90 mmHg, HR < 100 bpm and no vasopressor support, were followed for 48 h, and finally classified according to the need for further treatment for persistent bleeding (defined as requiring additional red blood cell transfusion), initiation of vasopressors and/or bleeding control with surgery and/or angioembolization. Patients were labeled as "Occult shock" (OS) if they required any intervention or "Truly hemodynamically stable" (THD) if they did not. Regional tissue oxygenation (rSO₂) was measured non-invasively by near-infrared spectroscopy (NIRS) on the forearm. A vascular occlusion test was performed, allowing a 3-min deoxygenation period and a reoxygenation period following occlusion release. Minimal rSO₂ (rSO₂min), Delta-down (rSO₂-rSO₂min), maximal rSO₂ following cuff-release (rSO₂max), and Delta-up (rSO₂max-rSO₂min) were computed. The NIRS response to the occlusion test was also measured in a control group of healthy volunteers.

RESULTS

Sixty-six consecutive trauma patients were included. After 8 h, 17 patients were classified as AHD, of whom five were finally considered to have OS and 12 THD. No hemodynamic, metabolic or coagulopathic differences were observed between the two groups, while NIRS-derived parameters showed statistically significant differences in Delta-down, rSO₂min, and Delta-up.

CONCLUSIONS

After 8 h of care, NIRS evaluation with an occlusion test is helpful for identifying occult shock in apparently hemodynamically stable patients.

LEVEL OF EVIDENCE

IV, descriptive observational study.

TRIAL REGISTRATION

ClinicalTrials.gov Registration Number: NCT02772653.

When should indocyanine green be assessed in colorectal surgery, and at what distance from the tissue? Quantitative measurement using the SERGREEN program

BACKGROUND

Suture dehiscence is one of the most feared postoperative complications. Correct intestinal vascularization is essential for its prevention. Indocyanine green (ICG) is one of the methods used to assess vascularization, but this assessment is usually subjective. Our group designed the SERGREEN program to obtain an objective measurement of the degree of vascularization. We do not know how long after ICG administration the fluorescence of the tissues should be evaluated, or how far away the measurement should be performed. The aim of this study is to establish the optimal moment and distance for analyzing the fluorescence saturation of ICG.

METHODS

Prospective observational study in patients undergoing elective laparoscopic colorectal surgery. The optimal time for ICG analysis was tested in a sample of 20 patients (10 right colon and 10 left colon), and the optimal distance in a sample of ten patients. ICG was administered intravenously, and colon vascularization was quantified using SERGREEN; RGB (Red, Green, Blue) encoding was used. The intensity curve of the ICG was analyzed for ten minutes after its administration. Distances of 1, 3, and 5 cm were tested.

RESULTS

The intensity of fluorescence increased until 1.5 min after ICG administration (reaching figures of 112.49 in the right colon and 93.95 in the left). It then remained fairly stable until 3.5 min (98.49 in the right and 83.35 in the left), at which point it began to decrease gradually. ICG saturation was inversely proportional to the distance between the camera and the tissue. The best distance was 5 cm, where the confidence interval was narrower [CI 86.66-87.53].

CONCLUSION

The optimal time for determining ICG in the colon is between 1.5 and 3.5 min, in both right and left colon. The optimal distance is 5 cm. This information will help to establish parameters of comparison in normal and pathological situations.

Is there the same requirement to obtain the PhD degree in all the departments of surgery of the Spanish universities?

INTRODUCTION

The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale.

METHODS

Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery.

RESULTS

Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager.

CONCLUSIONS

There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.

Experimental study of the quantification of indocyanine green fluorescence in ischemic and non-ischemic anastomoses, using the SERGREEN software program

Tissue ischemia is a key risk factor in anastomotic leak (AL). Indocyanine green (ICG) is widely used in colorectal surgery to define the segments with the best vascularization. In an experimental model, we present a new system for quantifying ICG fluorescence intensity, the SERGREEN software. Controlled experimental study with eight pigs. In the initial control stage, ICG fluorescence intensity was analyzed at the level of two anastomoses, in the right and in the left colon. Control images of the two segments were taken after ICG administration. The images were processed with the SERGREEN program. Then, in the experimental ischemia stage, the inferior mesenteric artery was sectioned at the level of the anastomosis of the left colon. Fifteen minutes after the section, sequential images of the two anastomoses were taken every 30 min for the following 2 h. At the control stage, the mean scores were 134.2 (95% CI 116.3–152.2) for the right colon and 147 (95% CI 134.7–159.3) for the left colon (p = 0.174) (Scale RGB—Red, Green, Blue). The right colon remained stable throughout the experiment. In the left colon, intensity fell by 47.9 points with respect to the pre-ischemia value (p < 0.01). After the first post-ischemia determination, the values of the ischemic left colon remained stable throughout the experiment. The relative decrease in ICG fluorescence intensity of the ischemic left colon was 32.6%. The SERGREEN program quantifies ICG fluorescence intensity in normal and ischemic situations and detects differences between them. A reduction in ICG fluorescence intensity of 32.6% or more was correlated with complete tissue ischemia.

Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps (CELS): Observational study

PURPOSE

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

METHOD

Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

RESULTS

Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5-6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82.4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

CONCLUSION

CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

T1 Rectal Adenocarcinoma: a Different Way to Measure Tumoral Invasion Based on the Healthy Residual Submucosa with Its Prognosis and Therapeutic Implications

BACKGROUND

Surgical treatment of early rectal cancer T1 is either local excision or total mesorectal excision. The choice of surgery is based on the risk of metastatic lymph node involvement. The most important factor to consider is the degree of submucosal invasion. We present a different way to measure tumoral invasion derived from the measurement of the healthy residual submucosa with its prognosis and therapeutic implications METHODS: Observational study of tumor submucosal invasion in patients undergoing transanal endoscopic microsurgery was conducted. Parameters evaluated are submucosal invasion, measuring the healthy residual submucosa at the point of maximum invasion; macroscopic morphology of the tumor; presence of muscularis mucosa, muscularis propria, and measurement of submucosa in the tumor area and the healthy area. The classification proposed is compared with the ones previously published.

RESULTS

Eighty consecutive patients diagnosed with T1 rectal cancer underwent transanal endoscopic microsurgery. Seventeen tumors (21.3%) were polypoid. En bloc resection was achieved in 77 (96.3%). The muscularis mucosa was present in 28 (35%), and the muscularis propria in 77 (96.3%) (p < 0.001). The healthy residual submucosa in the tumor area measured 2,343 ± 1,869 μm. Agreement was moderate with the Kikuchi classification (kappa 0.58) and very good with the Kudo classification (kappa 0.87).

CONCLUSIONS

We describe a method for measuring submucosal invasion in T1 rectal cancer which does not depend on the morphology of the lesion or on the presence of the muscularis mucosa. It can be applied to all T1 classifications of the digestive tract in which the muscularis propria is present.

Preoperative Diagnostic Uncertainty in T2-T3 Rectal Adenomas and T1-T2 Adenocarcinomas and a Therapeutic Dilemma: Transanal Endoscopic Surgery, or Total Mesorectal Excision?

BACKGROUND

Endorectal ultrasound and rectal magnetic resonance are sometimes unable to differentiate between stages T2 and T3 in rectal adenomas that are possible adenocarcinomas, or between stages T1 and T2 in rectal adenocarcinomas. These cases of diagnostic uncertainty raise a therapeutic dilemma: transanal endoscopic surgery (TES) or total mesorectal excision (TME)?

METHODS

An observational study of a cohort of 803 patients who underwent TES from 2004 to 2021. Patients operated on for adenoma (group I) and low-grade T1 adenocarcinoma (group II) were included. The variables related to uncertain diagnosis, and to the definitive pathological diagnosis of adenocarcinoma stage higher than T1, were analyzed.

RESULTS

A total of 638 patients were included. Group I comprised 529 patients, 113 (21.4%) with uncertain diagnosis. Seventeen (15%) eventually had a pathological diagnosis of adenocarcinoma higher than T1. However, the variable diagnostic uncertainty was a risk factor for adenocarcinoma above T1 (OR 2.3, 95% CI 1.1-4.7). Group II included 109 patients, eight with uncertain diagnosis (7.3%). Two patients presented a definitive pathological diagnosis of adenocarcinoma above T1.

CONCLUSIONS

On the strength of these data, we recommend TES as the initial indication in cases of diagnostic uncertainty. Multicenter studies with larger samples for both groups should now be performed to further assess this strategy of initiating treatment with TES.

How to Learn a Complex Endoscopic Procedure: Knots in Transanal Endoscopic Surgery: Different Skill Among Surgeons

PURPOSE

The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning.

MATERIALS AND METHODS

A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots.

RESULTS

Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P<0.001). At T1, 26 participants (81.3%) described the technique as difficult, but only 7 (21.9%) at T2 (P<0.001).

CONCLUSIONS

Performing the intrarectal knot suture is feasible. Despite the technical difficulty, the video tutorial is sufficient for surgeons to learn the technique.

Is there the same requirement to obtain the PhD degree in all the departments of surgery of the Spanish universities?

INTRODUCTION

The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale.

METHODS

Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery.

RESULTS

Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager.

CONCLUSIONS

There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.

Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps (CELS): observational study

PURPOSE

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

METHOD

Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

RESULTS

Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 - 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

CONCLUSION

CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Management of intra- and postoperative complications during TEM/TAMIS procedures: a systematic review

INTRODUCTION

Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management.

EVIDENCE ACQUISITION

A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications.

EVIDENCE SYNTHESIS

A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%.

CONCLUSIONS

Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.

Management of intra- and post-operative complications during TEM/TAMIS procedures. A systematic review

INTRODUCTION

Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and post-operative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management.

EVIDENCE ACQUISITION

A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications.

EVIDENCE GATHERING

A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%.

CONCLUSIONS

Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.

Urinary catheter in colorectal surgery: current practices and improvements in order to allow prompt removal. A cross-sectional study

BACKGROUND

Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery.

METHODS

Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum.

RESULTS

Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3.

CONCLUSIONS

Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.

Urinary catheter in colorectal surgery: current practices and improvements in order to allow prompt removal. A cross-sectional study

BACKGROUND

Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery.

METHODS

Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum.

RESULTS

Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3.

CONCLUSIONS

Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.

Botulinum toxin A as an adjunct to giant inguinal hernia reparation

La toxina botulínica se ha aplicado en la reparación de defectos ventrales, pero la literatura sobre su aplicación en hernias inguinoescrotales es escasa. Presentamos el caso de un paciente con hernia inguinoescrotal gigante. Se realiza tomografía computada basal y otra a las 4 semanas de la administración de toxina botulínica en la musculatura oblicua y en el recto abdominal (reducción de grosor e incremento de longitud de la musculatura). Se repara la pared abdominal mediante la colocación de una malla tipo BioA intraperitoneal y otra tipo DynaMesh^® retromuscular. La toxina puede tener un papel importante como adyuvante en la reparación de hernias inguinoescrotales con pérdida de domicilio.

Botulinum toxin has been used in ventral defects repair, but literature on its application in inguinoscrotal hernias is scarce. Patient with giant inguinoscrotal hernia. A baseline CT scan is performed and it is repeated four weeks after botulinum toxin injection in oblique musculature and in the abdominal rectum (reduction in thickness and increase in muscle length is observed). The abdominal wall is repaired by placing an intraperitoneal BioA mesh and a retromuscular DynaMesh^® mesh. The toxin can have an important role as an adjuvant in the reparation of inguinoscrotal hernias with loss of domain.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados.

Is obesity a factor of surgical difficulty in transanal endoscopic surgery?

BACKGROUND

The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients.

METHODS

Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) < 30 kg/m² and BMI ≥30 kg/m², the latter defined as obese.

RESULTS

From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation.

CONCLUSION

There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m²). TES in those obese patients does not represent a factor of surgical difficulty.

How to start and develop a multicenter, prospective, randomized, controlled trial

Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.

Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery

BACKGROUND

Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up.

METHOD

Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence.

RESULTS

TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis.

CONCLUSION

TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.

Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery: a randomized controlled trial

Background

Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA.

Methods

Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group.

Discussion

The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery.

Trial registration

Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: NCT03520088) (Date of registration 04/03/2018).

[Functional impairment and quality of life after rectal cancer surgery]

Objective

This study determines the quality of life and the anorectal function of these patients.

Method

Observational study of two cohorts comparing patients undergoing rectal tumor surgery using TaETM or conventional ETM after a minimum of six months of intestinal transit reconstruction. EORTC-30, EORTC-29 quality of life questionnaires and the anorectal function assessment questionnaire (LARS score) are applied. General variables are also collected.

Results

31 patients between 2011 and 2014: 15 ETM group and 16 TaETM. We do not find statistically significant differences in quality of life questionnaires or in anorectal function. Statistically significant general variables: longer surgical time in the TaETM group. Nosocomial infection and minor suture failure in the TaETM group.

Conclusion

The performance of TaETM achieves the same results in terms of quality of life and anorectal function as conventional ETM.

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Transanal endoscopic surgery is effective and safe after endoscopic polypectomy of potentially malignant rectal polyps with questionable margins

AIM

To determine the percentage of residual lesion observed in the pathology study of transanal endoscopic surgery (TEM) specimens after endoscopic polypectomy of malignant rectal polyps with questionable margins, and the need for further surgery. Secondary aims: to determine the morbidity and mortality associated with this procedure and to identify the percentage of recurrence after excision by TEM.

METHODS

Observational study with prospective data collection of all patients undergoing TEM after endoscopic polypectomy for malignant rectal polyps or non-invasive high-grade neoplasia, from January 2004 to December 2016. An en bloc full-thickness wall excision of the scar was performed. Variables recorded: histology of TEM specimen, 30-day morbidity and mortality according to the Clavien-Dindo classification, need for salvage surgery and recurrence.

RESULTS

Fifty out of 690 patients undergoing TEM during the study period (36 adenocarcinomas, five non-invasive high-grade neoplasias and 9 neuroendocrine tumors) were included. Post-surgery histology showed residual lesion in 21 (42%) patients: 7 neuroendocrine tumors, 10 adenomas and 4 adenocarcinomas (two pT1, one pT2 and one pT3). The pT2 and pT3 patients (4%) underwent salvage surgery. No recurrence was observed, and mean follow-up was 29.1Â ± 21.6 months. The 30-day morbidity rate was 14%, but 4/7 with Clavien-Dindo grade I.

CONCLUSIONS

After endoscopic polypectomy of malignant rectal polyps with questionable margins, the presence of residual lesion in the pathology study of transanal resection specimens is high. TEM with full-thickness resection of these lesions is an appropriate treatment, allowing disease control and achieving minimal morbidity.

The use of the Shock Index as a predictor of active bleeding in trauma patients

INTRODUCTION

Vital signs indicate the presence of bleeding only after large amounts of blood have been lost, with high morbidity and mortality. The Shock Index (SI) is a hemorrhage indicator with a cut-off point for the risk of bleeding at 0.9. The aim of this study is to assess whether a cut-off of≥0.8 is more sensitive for detecting occult bleeding, providing for early initiation of therapeutic maneuvers.

METHODS

SI analytical validation study of severe trauma patients older than 16 years of age. Vital signs were recorded, and scales for predicting bleeding included: SI, Assessment of Blood Consumption score, and Pulse Rate Over Pressure score. The relationship between the SI and 5 markers for bleeding was analyzed: need for massive transfusion, angiographic embolization, surgical bleeding control, death due to hypovolemic shock, and the overall predictor «active bleeding» (defined as the presence of at least one of the 4 markers above).

RESULTS

Data from 1.402 trauma patients were collected prospectively over a period of 10 years. The mean Injury Severity Score was 20.9 (SD 15.8). The mortality rate was 10%. The mean SI was 0.73 (SD 0.29). «Active bleeding» was present in 18.7% of patients. The SI area under the ROC curve for «active bleeding» was 0.749.

CONCLUSIONS

An SI cut-off point≥0.8 is more sensitive than≥0.9 and allows for earlier initiation of resuscitation maneuvers in patients with occult active bleeding.

How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery

BACKGROUND

The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM).

METHODS

This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and <15 cm (group B) from the anal verge.

RESULTS

During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p < 0.001), surgical time (p < 0.001) and peritoneal cavity perforation, which were all increased in group A.

CONCLUSION

TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.

Neoadjuvant therapy and transanal endoscopic surgery in T2-T3 superficial, N0, M0 rectal tumors. Local recurrence, complete clinical and pathological response

INTRODUCTION

The association of preoperative chemoradiotherapy and transanal endoscopic surgery in T2 and superficial T3 rectal cancers presents promising results in selected patients. The main objective is to evaluate the long-term loco-regional and systemic recurrence and, as secondary objectives, to provide results of postoperative morbidity and the correlation between complete clinical and pathological response.

METHODS

This is a retrospective observational study including a consecutive series of patients with T2-T3 superficial rectal cancer, N0, M0 who refused radical surgery (2008-2016). The treatment consisted of preoperative chemotherapy (5-fluorouracil or capecitabine) combined with radiotherapy (50, 4Gy) and transanal endoscopic surgery after 8weeks. Preoperative, surgical, pathological and long-term oncologic results were analyzed.

RESULTS

Twenty-four patients were included in the study. Two of them required rescue radical surgery for unfavorable pathological results. A local recurrence (4.5%) was observed and 2patients presented systemic recurrence (9%), with a median follow-up of 45 months. A complete clinical tumor response was achieved in 12 patients (50%), and complete pathological tumor response in 9 patients (37.5%). Postoperative complications were observed in 5 patients (20.8%), and they were mild except one. There was no postoperative mortality.

CONCLUSIONS

In this stage of rectal cancer, our results seem to support this strategy, mainly when a complete pathological response is achieved. The complete clinical tumor response does not coincide with the pathological tumor response. Randomized prospective studies should be performed to standardize this treatment.

Solitary fibrous tumor of the liver. Case report and review of the literature

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor. Given its origin, it can appear in almost any location. In the literature, only 50 cases of SFT in the liver parenchyma have been reported. Despite its rarity, this entity should be included in the differential diagnosis of liver masses. We report the first case with imaging data from five years prior to diagnosis, which was treated by right portal embolization and arterial tumor embolization, and subsequent liver resection. We also present an exhaustive review of the cases described to date.

Transanal endoscopic surgery in rectal cancer

Total mesorectal excision (TME) is the standard treatment for rectal cancer, but complications are frequent and rates of morbidity, mortality and genitourinary alterations are high. Transanal endoscopic microsurgery (TEM) allows preservation of the anal sphincters and, via its vision system through a rectoscope, allows access to rectal tumors located as far as 20 cm from the anal verge. The capacity of local surgery to cure rectal cancer depends on the risk of lymph node invasion. This means that correct preoperative staging of the rectal tumor is necessary. Currently, local surgery is indicated for rectal adenomas and adenocarcinomas invading the submucosa, but not beyond (T1). Here we describe the standard technique for TEM, the different types of equipment used, and the technical limitations of this approach. TEM to remove rectal adenoma should be performed in the same way as if the lesion were an adenocarcinoma, due to the high percentage of infiltrating adenocarcinomas in these lesions. In spite of the generally good results with T1, some authors have published surprisingly high recurrence rates; this is due to the existence of two types of lesions, tumors with good and poor prognosis, divided according to histological and surgical factors. The standard treatment for rectal adenocarcinoma T2N0M0 is TME without adjuvant therapy. In this type of adenocarcinoma, local surgery obtains the best results when complete pathological response has been achieved with previous chemoradiotherapy. The results with chemoradiotherapy and TEM are encouraging, but the scientific evidence remains limited at present.

The prevalence of parastomal hernia after formation of an end colostomy. A new clinico-radiological classification

INTRODUCTION

Parastomal hernia (PH) is a common complication of end colostomy, found in over 50% of patients. Abdominal computerized tomography (CT) may help diagnosis. The prevalence of PH may be higher than previously reported. We present a new CT classification for use in clinical practice.

METHOD

A cross-sectional, descriptive observational study was carried out, assessing the clinical and radiological prevalence of PH in 75 patients with an end colostomy operated on since 1997. Clinical examinations were performed by a single surgeon. Abdominal CTs were assessed by a single radiologist.

RESULTS

PH was observed clinically in 33 (44%) of 75 patients and 27 (82%) were symptomatic. Using the classification 0 (Normal), I (Hernial sac containing stoma loop), II (Sac containing omentum), III (Sac containing a loop other than stoma), radiological PH was observed in 35 (47%) patients. Clinical/radiological concordance (Kappa index = 0.4) increased proportionally with sac size. All type-III PHs (n = 9) were symptomatic. The combined prevalence of PH detected by one or other method was 60.8%.

CONCLUSION

Clinical and radiological prevalence of PH is high. As there is no gold standard for PH detection, we recommend a combination of the two methods. A new classification for use in clinical practice is proposed.

The European experience with vascular injuries

The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.