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.

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.

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.

Long-term outcomes of colonic stent as a "bridge to surgery"for left-sided malignant large-bowel obstruction.

BACKGROUND: The role of self-expandable metallic stents (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction is still debated. Here we assess the morbidity, mortality and long-term oncological outcomes as a bridge to surgery for patients with left-sided malignant colonic obstruction. METHOD: Prospective observational study with retrospective analysis of patients with left-sided malignant colonic obstruction undergoing stenting. April 2006-April 2018. We assessed all patients with intent-to treat and per protocol analyses and long-term follow-up variables. RESULTS: Colonic stent was performed in 117 patients. Technical and clinical success of SEMS placement: 94.4% (111/117), only 4.3% perforation. Elective surgery resection following the strategy of SEMS was performed in 83.8% (98/117). A laparoscopic approach was: 25.6% (30/117); 76.9% in the last two years. Primary anastomosis rate: 92.8% (91/98), without protective stoma in any patients. Anastomotic leakage rate: 8.2% (8/97). Median follow-up: 44.5 months (range 0-109). The intent-to-treat analysis showed overall and disease-free survival rates of 63.3% (74/117) and 58.1% (68/117), and local and distant recurrence rates: 9.4% (11/117) and 58.1% (68/117). In the per protocol analysis, overall and disease-free survival rates: 63.2% (62/98) and 60.2% (58/98), and local and distant recurrence rates: 10.2% (10/98) and 36.7% (36/98). Disease progression was predominantly observed during the first 5 years' follow-up as disease recurrence; after five years' follow-up, 60% of the patients were disease-free. CONCLUSIONS: According to the results of the study SEMS as a bridge to surgery achieves perioperative results comparable to non-occlusive colonic cancer surgery and does not adversely affect long-term oncological outcomes. Further investigations are needed.

Comité quirúrgico para la hidradenitis supurativa: nuestra experiencia / Hidradenitis Suppurative: Our Experience with a Surgical Case Management Team

ANTECEDENTES Y OBJETIVOS: La complejidad del tratamiento de la hidradenitis supurativa (HS) hace necesario un abordaje multidisciplinar, y con este fin diseñamos un comité quirúrgico para su abordaje. Este estudio describe las características clínicas de los pacientes evaluados y los resultados de las técnicas quirúrgicas realizadas. MATERIAL Y MÉTODOS: Presentamos un estudio descriptivo transversal que recoge 104 pacientes que fueron evaluados en nuestro comité desde setiembre de 2015 hasta julio de 2018. RESULTADOS: En nuestra serie, el 46% de los pacientes con HS evaluados recibieron tratamiento quirúrgico. La mayoría fueron varones (73%), sin antecedentes familiares de HS (63%), exfumadores o fumadores (76%). El fenotipo clínico predominante fue el tipo III (41%), con presencia de patología grave en la mayor parte de los casos (36% con Hurley II y 46% con Hurley III). Las áreas anatómicas más afectadas fueron las axilas (51,9%) y las ingles (41,3%); mientras que las intervenidas con mayor frecuencia fueron la axilar (38,3%), seguida de la glútea (23,4%). Entre los tratamientos médicos, el más usado fue la combinación de rifampicina con clindamicina. El destechamiento (deroofing) se posicionó como la técnica quirúrgica más empleada entre los pacientes intervenidos (hasta en un 48%). En cuanto al resultado posquirúrgico global: un 63,4% obtuvo un resultado satisfactorio, un 20% recidivó y un 12% presentó dehiscencia de la herida quirúrgica. CONCLUSIONES: Dada nuestra experiencia, recomendamos la instauración de comités multidisciplinares para mejorar la comunicación entre los diferentes especialistas, así como individualizar el tratamiento y mejorar el seguimiento de los pacientes con HS

BACKGROUND AND OBJECTIVES: The complexity of hidradenitis suppurativa (HS) treatment calls for a multidisciplinary approach. We therefore created a multidisciplinary team to manage surgical care. This study aimed to describe the clinical characteristics of the patients we evaluated and the outcomes of the surgical techniques used. MATERIAL AND METHODS: Descriptive cross-sectional study of 104 patients evaluated by our surgical case management team between September 2015 and July 2018. RESULTS: Surgery was used to treat 46% of the patients with HS who were evaluated. Most were men (73%) with no family history of HS (63%) and smokers or former smokers (76%). Gluteal HS comprised the largest phenotype group (41%) and the majority of cases were serious (Hurley stage II, 36%; stage III, 46%). The anatomical regions with the largest number of lesions were the axillae (51.9%) and the groin (41.3%). Surgery was most often performed in the axilla (38.3%), followed by the gluteus (23.4%). The most common drug treatment was a combination of rifampicin and clindamycin, Deroofing was the technique used most often (in 48% of the patients who underwent surgery). Postoperative outcomes were assessed as satisfactory overall in 63.4% of the cases. The HS lesion recurred in 20% and 12% developed wound dehiscence. CONCLUSIONS: Our experience leads us to recommend forming multidisciplinary teams to improve communication between specialists, provide tailored treatment for the patient with HS, and improve follow-up

Hidradenitis Suppurative: Our Experience with a Surgical Case Management Team. / Comité quirúrgico para la hidradenitis supurativa: nuestra experiencia.

BACKGROUND AND OBJECTIVES: The complexity of hidradenitis suppurativa (HS) treatment calls for a multidisciplinary approach. We therefore created a multidisciplinary team to manage surgical care. This study aimed to describe the clinical characteristics of the patients we evaluated and the outcomes of the surgical techniques used. MATERIAL AND METHODS: Descriptive cross-sectional study of 104 patients evaluated by our surgical case management team between September 2015 and July 2018. RESULTS: Surgery was used to treat 46% of the patients with HS who were evaluated. Most were men (73%) with no family history of HS (63%) and smokers or former smokers (76%). Gluteal HS comprised the largest phenotype group (41%) and the majority of cases were serious (Hurley stage II, 36%; stage III, 46%). The anatomical regions with the largest number of lesions were the axillae (51.9%) and the groin (41.3%). Surgery was most often performed in the axilla (38.3%), followed by the gluteus (23.4%). The most common drug treatment was a combination of rifampicin and clindamycin, Deroofing was the technique used most often (in 48% of the patients who underwent surgery). Postoperative outcomes were assessed as satisfactory overall in 63.4% of the cases. The HS lesion recurred in 20% and 12% developed wound dehiscence. CONCLUSIONS: Our experience leads us to recommend forming multidisciplinary teams to improve communication between specialists, provide tailored treatment for the patient with HS, and improve follow-up.

A scoring system to predict complex transanal endoscopic surgery.

BACKGROUND: Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience. METHOD: Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion. RESULTS: During the study period, 773 TEMs were performed, 708 of which met the study's inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.78, 95% CI 1.1-2.9, score: 1), tumor size > 5 cm (OR: 5.1, 95% CI 3.2-8.2, score: 4), TEM for recurrence (OR: 6.3, 95% CI 2.3-16.7, score: 5), and distance from the upper margin of the tumor to the anal verge > 15 cm (OR: 1.6, 95% CI 0.96-2.7, score: 1). CONCLUSIONS: Rather than establishing the learning curve merely in terms of the number of TEM procedures performed, it is important to consider the surgical difficulty of the interventions. To this end, it is essential to differentiate simple TEMs from the complex ones.

Transanal endoscopic microsurgery in very large and ultra large rectal neoplasia.

BACKGROUND: Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign rectal lesions and early rectal cancer (T1). The size classification of rectal polyps is controversial. Some articles define giant rectal lesions as those larger than 5 cm, which present a significantly increased risk of complications. The aim of this study was to evaluate the feasibility of TEM in these lesions. METHODS: An observational descriptive study with prospective data collection evaluating the feasibility of TEM in large rectal adenomas was performed between June 2004 and September 2018. Patients were assigned to one of the three groups according to size: < 5 cm, very large (5-7.9 cm) and ultra-large (≥ 8 cm). Descriptive and comparative analyses between groups were performed. RESULTS: TEM was indicated in 761 patients. Five hundred and seven patients (66.6%) with adenoma in the preoperative biopsy were included in the study. Three hundred and nine out of 507 (60.9%) tumors < 5 cm, 162/507 (32%) very large tumors (5-7.9 cm) and 36/507 (7.1%) ultra-large tumors (≥ 8 cm) were reviewed. Morbidity increased with tumor size: 17.5% in tumors < 5 cm, 26.5% in those 5-7.9 cm, and 36.1% in those > 8 cm. Peritoneal perforation, fragmentation, free margins and stenosis were also more common in very large and ultra-large tumors (p < 0.001). There were no statistical differences between the groups in the definitive pathology (p = 0.38). CONCLUSIONS: TEM in these large tumors is associated with higher rates of morbidity, peritoneal perforation, free margins and stenosis. Although these tumors do not require total mesorectal excision and are eligible for TEM, the surgery must be carried out by experienced surgeons.

Transanal endoscopic micro-surgery in elderly and very elderly patients: a safe option? Observational study with prospective data collection.

BACKGROUND: Although the incidence of colorectal cancer increases with the patient's age, the elderly continue to be less likely to be scheduled for surgery. Transanal endoscopic micro-surgery (TEM) is a surgical alternative to total mesorectal excision (TME) in early stage rectal cancer and/or in selected patients that could decrease morbidity and mortality rates in this group of patients. Our main objective is to assess the safety and feasibility of TEM in elderly (75-84 years) and very elderly (≥ 85 years) patients. METHODS: Observational study was conducted with prospective data collection of all consecutive patients who underwent TEM between April 2004 and January 2017. Patients were assigned to groups according to age. Descriptive and comparative analyses between groups were performed. RESULTS: We analyzed 693 patients, 429 patients < 75 years (61.9%), 220 patients between the ages of 75 and 84 (31.7%), and 44 patients ≥ 85 years old (6.3%). The tendency in our series is to increase comorbidities with age. Palliative or consensus intent was more frequently performed in elderly (10.5%, 34/220), and very elderly (45.4%, 20/44), compared with the youngest (6.3%, 27/429), (p < 0.001). Global morbidity presented an increasing trend related to age from 20.3% in < 75 years, to 25.9% in elderly and 34.1% in very elderly. Surgical complications were recorded in 18.5% (128/693) of patients with no significant differences between groups. The most common one was rectal bleeding 16.1% (111/693). Significant differences were found in non-surgical complications, recorded in 7.3% (16/220) in the elderly, and 15.9% (7/44) in the group above 84 years (p = 0.013). CONCLUSIONS: TEM presents acceptable morbidity rates mainly due to non-surgical-related adverse effects in elderly and very elderly patients and may be a feasible and safe alternative in this population in both curative and non-curative indications.

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.