ABSTRACT
INTRODUCTION: Temporary ileostomy is a valuable aid in reducing the severity of complications related to rectal cancer surgery. However, it is still unclear what is the best timing of its closure in relation to the feasibility of an adjuvant treatment, especially considering patient-reported outcomes and health system costs. The aim of the study is to compare the results of an early versus late closure strategy in patients with indication to adjuvant chemotherapy after resection for rectal cancer. METHODS AND ANALYSIS: This is a prospective multicentre randomised trial, sponsored by Rete Oncologica Piemonte e Valle d'Aosta (Oncology Network of Piedmont and Aosta Valley-Italy). Patients undergone to rectal cancer surgery with temporary ileostomy, aged >18 years, without evidence of anastomotic leak and with indication to adjuvant chemotherapy will be enrolled in 28 Network centres. An early closure strategy (between 30 and 40 days from rectal surgery) will be compared with a late one (after the end of adjuvant therapy). Primary endpoint will be the compliance to adjuvant chemotherapy with and without ileostomy. Complications associated with stoma closure as well as quality of life, costs and oncological outcomes will be assessed as secondary endpoints. ETHICS AND DISSEMINATION: The trial will engage the Network professional teams in a common effort to improve the treatment of rectal cancer by ensuring the best results in relation to the most correct use of resources. It will take into consideration both the patients' point of view (patient-reported outcome) and the health system perspective (costs analysis). The study has been approved by the Ethical Review Board of Città della Salute e della Scienza Hospital in Turin (Italy). The results of the study will be disseminated by the Network website, medical conferences and peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT04372992.
Subject(s)
Ileostomy , Rectal Neoplasms , Aged , Chemotherapy, Adjuvant , Humans , Italy , Postoperative Complications , Prospective Studies , Quality of Life , Rectal Neoplasms/drug therapy , Rectal Neoplasms/surgery , Time FactorsABSTRACT
BACKGROUND: Rectal cancer treatment is still a challenging frontier in general surgery, as there is no general agreement on which surgical approach is best for its management. Total mesorectal excision (TME), influenced the practical approach to rectal cancer, and brought a significant improvement on tumor recurrence and patients survival. Robotic transanal surgery is a newer approach to rectal dissection whose purpose is to overcome the limits of the traditional transabdominal approach, improving accuracy of distal dissection and preservation of hypogastric innervation. An increasing interest on this new technique has raised, thanks to the excellent pathological and acceptable short-term clinical outcomes reported. MATERIALS AND METHODS: Three consecutive cases of robotic transanal TME were prospectically performed between May 2017 and October 2017. RESULTS: TME quality was Quirke 3 grade in all cases. Mean operative time was 530â¯min. None of the patients had intra-operatively or post-operatively complications. CONCLUSIONS: Robotic transanal TME is a very recent procedure. Acclaimed greatest advantage of robotic transanal TME is the facilitation of dissection with an in-line view, which translates in an improved surgical field exposure and visualization. Further investigations are needed to assure the actual value of robotic transanal approach.
ABSTRACT
Spontaneous barogenic rupture of the esophagus is a rare disease with high morbidity and mortality. Many therapeutic options are available. Esophagectomy is indicated when a large rupture is found with huge mediastinal contamination. Here, we describe a minimal invasive esophagectomy procedure for an esophageal barogenic rupture. A thoracoscopic esophagectomy was performed with the patient in a prone position. After a laparoscopic gastric tubulization, a cervical esopagho-gastro anastomosis was performed with a retro-sternal passage of the stomach in order to avoid the heavily contaminated posterior mediastinum. The postoperative outcome was almost uneventful. This minimal-invasive approach allowed direct optimal visualization of the esophageal laceration and a thorough mediastinal cleansing, thereby avoiding any septic complications, which are the major concern in this particular clinical procedure. In our case, the esophagectomywas mandatory because of the large laceration and massive mediastinal contamination. The minimal invasive thoracoscopic and laparoscopic esophagectomy approach is feasible even in an emergency setting. This is the first report of this procedure being used in a high-risk patient with Boerhaave's syndrome.
