Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Theoretical advantages of Turnbull-Cutait pull-through delayed coloanal anastomosis (DCAA) are a reduced risk of anastomotic leak and therefore avoidance of stoma. Gradually abandoned in favor of immediate coloanal anastomosis (ICAA) with diverting stoma, DCAA has regained popularity in recent years in reconstructive surgery for low RC, especially when combined with minimally invasive surgery (MIS). The aim of this study was to perform the first meta-analysis, exploring the safety and outcomes of DCAA compared to ICAA with protective stoma. METHODS: A systematic search of MEDLINE, EMBASE, and CENTRAL and Google Scholar databases was performed for studies published from January 2000 until December 2020. The systematic review and meta-analysis were performed according to the Cochrane Handbook for Systematic Review on Interventions recommendations and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. RESULTS: Out of 2626 studies screened, 9 were included in the systematic review and 4 studies in the meta-analysis. Outcomes included were postoperative complications, pelvic sepsis and risk of definitive stoma. Considering postoperative complications classified as Clavien-Dindo III, no significant difference existed in the rate of postoperative morbidity between DCAA and ICAA (13% versus 21%; OR 1.17; 95% CI 0.38-3.62; p = 0.78; I2 = 20%). Patients in the DCAA group experienced a lower rate of postoperative pelvic sepsis compared with patients undergoing ICAA with diverting stoma (7% versus 14%; OR 0.37; 95% CI 0.16-0.85; p = 0.02; I2 = 0%). The risk of definitive stoma was comparable between the two groups (2% versus 2% OR 0.77; 95% CI 0.15-3.85; p = 0.75; I2 = 0%). CONCLUSIONS: According to the limited current evidence, DCAA is associated with a significant decrease in pelvic sepsis. Further prospective trials focusing on oncologic and functional outcomes are needed.

Integration of transanal techniques for precise rectal transection and single-stapled anastomosis: a proof of concept study.

AIM: Transection of the distal rectum and subsequent anastomosis differ between the open, minimally invasive and transanal approaches. With the transanal technique, there is direct control of the transection level and the single-stapled anastomosis, thus overcoming two crucial limitations of rectal surgery. This study describes a technique for precise a transanal rectal transection with a single-stapled (TTSS) colorectal, coloanal or ileoanal anastomosis in 20 consecutive patients undergoing low rectal surgery. METHODS: After completing rectal dissection by the preferred technique (open or minimally invasive), TTSS was created. The detailed video describes this technique. RESULTS: TTSS was feasible in all patients: 13 underwent total mesorectal excision + TTSS for low rectal cancer and seven underwent ileoanal pouch + TTSS for benign disease. Complications included one Grade IIIa and three Grade I, according to the Clavien-Dindo classification (median follow-up 6 months). CONCLUSION: TTSS represents a technique which can be applied regardless of the preferred approach (open, minimally invasive or transanal) for low rectal dissection. The adoption of TTSS could well allow for a more consistent comparison of the outcomes following the differing approaches to rectal surgery.

In vivo evidence that the cannabinoid receptor 2-63 RR variant is associated with the acquisition and/or expansion of HIV infection.

OBJECTIVES: The aim of the study was to investigate whether the rs35761398 variants of the cannabinoid receptor 2 (CB2) gene may influence the acquisition of HIV infection and the clinical presentation of HIV/hepatitis C virus (HCV) coinfection. METHODS: We compared 166 HIV/HCV-coinfected patients with 186 HCV-monoinfected patients, all with biopsy-proven chronic hepatitis (using the Ishak scoring system), naïve for anti-HCV treatment and tested for the CB2 rs35761398 polymorphism (using the TaqMan assay). RESULTS: The HIV/HCV-coinfected patients were more frequently male (P < 0.002), were younger (P < 0.001), and had lower median BMI (P < 0.001) and HCV RNA (P < 0.05) and higher median aspartate aminotransferase (AST; P < 0.001), alanine aminotransferase (ALT; P < 0.001) and gamma glutamyl transferase (GGT; P < 0.001) levels than the HCV-monoinfected patients. The CB2 RR variant predominated in HIV/HCV-coinfected patients (45.8% vs. 31.2% in HCV-monoinfected patients; P < 0.001) and the CB2 QR variant in HCV-monoinfected patients (57.5% vs. 38.6% in HIV/HCV-coinfected patients; P < 0.00001), and the CB2 QQ variant was equally distributed. Focusing on patients with the CB2 QQ variant, the 26 HIV/HCV-coinfected patients, compared with the 21 HCV-monoinfected patients, showed less severe liver necroinflammation [lower histological activity index (HAI)] (P < 0.05). Of the patients with the CB2 RR variant, the 76 HIV/HCV-coinfected patients, compared with the 58 HCV-monoinfected patients, were more frequently male (P < 0.05), were younger (P < 0.001), and had a lower median body mass index (BMI; P < 0.001), a higher median AST level (P < 0.001), a higher mean HAI score (P < 0.05) and a higher rate of cases with severe steatosis (P = 0.05). In an analysis of variance (anova) of HCV/HIV-coinfected and HCV-monoinfected patient data, those with the CB2 RR variant (P = 0.003) and of male sex (P = 0.002) were more prevalent in the HCV/HIV-coinfected group. CONCLUSIONS: There is the suggestion of a positive effect of the CB2 RR variant on HIV acquisition and/or spread, which is in accordance with previous in vitro observations.

Impact of PNPLA3 variants on liver histology of 168 patients with HIV infection and chronic hepatitis C.

This study analysed the impact of PNPLA3 variants on liver histology of 168 HIV/hepatitis C virus (HCV)-coinfected patients who were naïve for HCV treatment. A athologist unaware of the patients' condition graded liver fibrosis and necroinflammation (Ishak) and steatosis (Kleiner). Patients were tested for PNPLA3 variants and genotyped for the PNPLA3 rs738409 C to G variant underlying the I148M substitution. All were hepatitis B surface antigen negative and stated no alcohol abuse. The mean age was 40.6 (37.6-44.1) years, 72.6% were males, 42% had HCV genotype 3, 38.9% HCV genotype 1 and 79.2% were receiving highly active antiretroviral therapy. The 79 patients with the PNPLA3 p.148I/M or M/M variants more frequently showed severe steatosis (score 3-4) than the 89 with PNPLA3 p.148I/I (43% vs. 24.7%, p 0.001), whereas no difference was observed in the degree of necroinflammation or fibrosis. Compared with 112 patients with lower scores, 56 with severe steatosis showed higher body mass index (p 0.03), higher rate of HCV genotype 3 (55.6% vs. 35.2%, p 0.01), PNPLA3 p.148I/M or M/M (60.7% vs. 39.3%, p 0.01) and lower CD4(+) cells/mm(3) (514.00 (390.5-673.0) vs. 500.00 (399.0-627.0); p 0.002). At multivariate analysis, body mass index (p 0.01), HCV genotype 3 (p 0.006), CD4(+) cell count (p 0.005) and PNPLA3 p.148I/M or M/M variants (p 0.01) were found to be independent predictors of severe liver steatosis. The PNPLA3 p.148 I/M or M/M variants and CD4(+) cell count were the only independent predictors of severe steatosis in patients with HCV non-3 genotypes. This is the first study to show that among HIV/HCV-coinfected patients the PNPLA3 p.148I/M or M/M variant have substantially less impact on steatosis for those with HCV genotype 3 than non-genotype 3.

Recurrence of rectal prolapse following rectopexy: a pooled analysis of 532 patients.

AIM: The study was designed to address the unanswered question of the influence of the extent of rectal mobilization, the type of rectal fixation and the surgical access (open vs laparoscopic) on recurrence rates following abdominal surgery for full-thickness rectal prolapse (FTRP). METHOD: Individual patient data were pooled and data merging was performed following comparison of variable definitions to ensure similarity in definitions. Recurrence after rectopexy was defined as the presence of FTRP on physical examination. The impact of categorical factors on recurrence was assessed using Fisher's exact and the chi-squared tests. Recurrence-free survival curves were generated for patients and differences in time to recurrence were compared using the log rank test. Factors passing univariate screening with a P value < 0.1 were included in a multivariate model. RESULTS: After data matching and merging, 532 patients were included. The duration of follow-up ranged from 12 to 235 months. There were 46 (8.6%) recurrences at a median follow-up of 60 months. Mean age was 53.6 ± 17 years, 359 (67.5%) were female, the mean length of external prolapse was 6.3 ± 4 cm, and previous abdominal surgery had taken place in 33.7%. Four variables were identified on initial univariate screening as being related to recurrence. They included a history of incontinence (P = 0.09), constipation (P = 0.018), the extent of rectal mobilization (P = 0.004) and the role of sigmoid resection (P = 0.057). Using multivariate analysis, only the degree of mobilization was independently associated with recurrence (P = 0.026). CONCLUSION: Circumferential rectal mobilization during rectopexy was associated with a decreased long-term recurrence rate. The type of rectal fixation and the type of surgical access did not influence recurrence.

Distribution of natural resistance to NS3 protease inhibitors in hepatitis C genotype 1a separated into clades 1 and 2 and in genotype 1b of HIV-infected patients.

Naturally occurring resistance-associated variants (RAVs) within the protease domain of hepatitis C virus (HCV) genotype (G) 1a separated into clades 1 and 2, and G1b were investigated in 59 HIV/HCV coinfected patients. RAVs were detected in 10/23 G1a/clade 1 and 1/19 G1b (p 0.0059). A similar frequency of RAVs was found when comparing G1a/clade 2 and G1b (p 0.1672). A cross-resistance to the macrocyclic compounds simeprevir and paritaprevir was detected in two G1a/clade 2 and 1 G1b sequences and none of G1a/clade 1 sequences. The simultaneous characterization of subtype and natural RAVs by population analysis of the NS3 domain by may add important information for anti-HCV treatment strategies including protease inhibitors.

Impact of a surgical site infection reduction strategy after colorectal resection.

AIM: This study was performed to determine the impact of a surgical site infection (SSI) reduction strategy on SSI rates following colorectal resection. METHOD: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2006-14 were utilized and supplemented by institutional review board-approved chart review. The primary end-point was superficial and deep incisional SSI. The inclusion criterion was colorectal resection. The SSI reduction strategy consisted of preoperative (blood glucose, bowel preparation, shower, hair removal), intra-operative (prophylactic antibiotics, antimicrobial incisional drape, wound protector, wound closure technique) and postoperative (wound dressing technique) components. The SSI reduction strategy was prospectively implemented and compared with historical controls (pre-SSI strategy arm). Statistical analysis included Pearson's chi-square test, and Student's t-test performed with spss software. RESULTS: Of 1018 patients, 379 were in the pre-SSI strategy arm, 311 in the SSI strategy arm and 328 were included to test durability. The study arms were comparable for all measured parameters. Preoperative wound class, operation time, resection type and stoma creation did not differ significantly. The SSI strategy arm demonstrated a significant decrease in overall SSI rates (32.19% vs 18.97%) and superficial SSI rates (23.48% vs 8.04%). Deep SSI and organ space rates did not differ. A review of patients testing durability demonstrated continued improvement in overall SSI rates (8.23%). CONCLUSION: The implementation of an SSI reduction strategy resulted in a 41% decrease in SSI rates following colorectal resection over its initial 3 years, and its durability as demonstrated by continuing improvement was seen over an additional 2 years.

A unique presentation of a renal clear cell carcinoma with atypical metastases.

INTRODUCTION: Renal cancer is a relatively common neoplasia with renal clear cell carcinoma being the most frequent histological type. This tumor has a strong tendency to metastasize virtually to all organs. Today, new diagnostic tools allow physicians to distinguish between those patients with "incidental findings" and those with advanced metastatic disease. PRESENTATION OF CASE: A 70-year-old male with multiple indolent subcutaneous masses underwent colonoscopy after a positive fecal screening test for colorectal carcinoma. A rectal lesion was discovered but biopsy was negative. CT scan revealed advanced renal cancer involving the peritoneal cavity, retroperitoneum and lung. Biopsy of subcutaneous masses confirmed the suspected metastases. The patient underwent surgery (an open left nephrectomy with rectosigmoid resection and metastases debulking) because of a high risk of bowel obstruction and increasing anemia. After three years of multi-targeted therapy and follow-up, the patient is still asymptomatic and in good general condition. DISCUSSION: Treatment of metastatic renal cancer is still controversial even if more than 30% of patients have metastasis at the time of diagnosis. Recently introduced targeted therapies are encouraging but still present problems with side effects and an unlimited period of efficacy. Although there is no consensus, several studies and guidelines consider metastasectomy to be a valid option. CONCLUSION: Recent series highlight surgery as a key-point in the management of advanced renal clear cell carcinoma. Our case demonstrates the validity of a surgical strategy supported by a multidisciplinary approach.

Ten-year follow up after laparoscopic suture rectopexy for full-thickness rectal prolapse.

AIM: Studies have shown that recurrence rates of full-thickness rectal prolapse (FTRP) 5 years after surgery can quadruple at 10 years. This study aimed to evaluate the impact of laparoscopic suture rectopexy for FTRP on recurrence rates and functional outcome at a median follow up of 10 years. METHOD: Prospectively collected data for patients who underwent laparoscopic suture rectopexy for FTRP between 1993 and 2006 were analysed. Laparoscopic rectopexy consisted of circumferential mobilization of the rectum down to the levator followed by suture suspension to promontory. Patients with preexisting constipation or who were unfit for general anaesthesia were not included. Incontinence, quality of life and constipation were assessed by validated scores. Recurrence-free curves were generated using the Kaplan-Meier method. RESULTS: One hundred and seventy-nine patients with a median age of 62 (15-93) years including 174 women and five men underwent laparoscopic suture rectopexy. There was no mortality. The 30-day complication rate was 4% (partial transection of the left ureter, pneumonia, urinary tract infection, urinary retention, superficial surgical site infection). Data on 172 patients (96%) were available at follow up. There were 10 recurrences of FTRP at 5-year follow up giving a crude recurrence rate of 6%. The actuarial 10-year recurrence rate was 20% (95% CI, 10.8-20.1). Follow-up continence (P < 0.0001) and quality of life were better than preoperatively: lifestyle (P < 0.001), coping (P < 0.001), self-perception (P < 0.005), embarrassment (P < 0.06). Constipation was unchanged. CONCLUSION: Laparoscopic suture rectopexy led to few complications, a recurrence rate of 20%, improved continence and quality of life with no worsening of constipation at 10 years.

Quality of total mesorectal excision and depth of circumferential resection margin in rectal cancer: a matched comparison of the first 20 robotic cases.

AIM: There are concerns about the impact of robotic proctectomy on the quality of total mesorectal excision (TME) and the impact of laparoscopic proctectomy on the depth of the circumferential resection margin (CRM). The aim of this study was to compare the first 20 consecutive robotic proctectomies performed in our unit with matched series of open and laparoscopic proctocolectomy performed by the same surgeon. METHOD: Data on the first 20 consecutive patients treated with robotic proctectomy for rectal cancer, <12 cm from the anal verge, by the senior author (RB) were extracted from a prospectively maintained database. Groups of patients treated with open and laparoscopic proctectomy, matched for age, gender and body mass index (BMI) with those undergoing robotic proctectomy, were selected. The quality of the TME was judged as complete, nearly complete or incomplete. CRM clearance was reported in millimetres. Physiological parameters and operative severity were assessed. RESULTS: Age (P = 0.619), Physiological and Operative Severity Score for the Enumeration of Morbidity and Mortality (POSSUM) score (P = 0.657), operative severity score (P = 0.977), predicted mortality (P = 0.758), comorbidities (P = 0.427), previous abdominal surgery (P = 0.941), tumour height (P = 0.912), location (P = 0.876), stage (P = 0.984), neoadjuvant chemoradiation (P = 0.625), operating time (P = 0.066), blood loss (P = 0.356), ileostomy (P = 0.934), conversion (P = 0.362), resection type (P = 1.000), flatus (P = 0.437), diet (P = 0.439), length of hospital stay (P = 0.978), complications (P = 0.671), reoperations (P = 0.804), reinterventions (P = 0.612), readmissions (P = 0.349), tumour size (P = 0.542; P = 0.532; P = 0.238), distal margin (P = 0.790), nodes harvested (P = 0.338) and pathology stage (P = 0.623) did not differ among the three groups. The quality of TME showed a trend to be lower following robotic surgery, although this was not statistically significant [open 95/5/15 (complete/nearly complete/incompete) vs laparoscopic 95/5/15 vs robotic 80/5/15; P = 0.235], but the degree of clearance at the CRM was significantly greater in robotic patients [open 8 (0-30) mm vs laparoscopic 4 (0-30) mm vs robotic 10.5 (1-30) mm; P = 0.02]. CONCLUSION: The study reports no statistically significant difference between open and laparoscopic techniques in the quality of TME during the learning curve of robotic proctectomy for rectal cancer and demonstrates an improved CRM.

Indocyanine green fluorescent dye during bowel surgery: are the blood supply "guessing days" over?

Assessing the blood supply of the bowel is a difficult task even for experienced surgeons. Laser-assisted indocyanine green (ICG) fluorescent dye angiography provides intraoperative visual assessment of blood flow to the bowel wall and surrounding tissues, allowing for modification to the surgical plan, which can reduce the risk of postoperative complications. ICG angiography was prospectively performed in a single center during a 1-year period for small bowel ischemia and left colorectal resections. ICG angiography played a major role in the intraoperative decision making in 4 of 160 patients, whose clinical and operative details are here reported. In case of acute small intestine ischemia, resection is not warranted unless absolute perfusion units are below 19 (relative 21%). When evaluating blood supply to the left colon prior to anastomosing, resection is recommended with absolute units lower than 18 (relative 31%) even if the bowel appears macroscopically perfused.