Surgical efficacy and learning curves of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: A retrospective two-center cohort study.

BACKGROUND: There is a potential benefit on long-term outcomes following complete mesocolic excision (CME) for right-sided colon cancer when compared to conventional colectomy. This study aims to analyze the learning curve and short-term outcomes of laparoscopic CME with intracorporeal anastomosis (ICA) for right-sided colon cancer in the hands of experienced colorectal surgeons. METHODS: A two-center cohort study of consecutive patients undergoing right-sided colectomy from September 2021 to May 2022 at two tertiary colorectal centers in Denmark. Learning curves of surgical time were estimated using a cumulative sum analysis (CUSUM). RESULTS: A total of 61 patients were included. According to the CUSUM analysis, 32 cases were needed to obtain a peak in operative time, resulting in a decrease in time consumption (group 1/learning phase: 217.2 min [SD 53.6] and group 2/plateau phase 191.6 min [SD 45.1], p = 0.05). There was a nonsignificant reduction in the rates of severe surgical complications (Clavien-Dindo > 3) (13% vs. 7%, p = 0.67) between the two groups, while the length of hospital stay remained constant (median 3.0 days, interquartile range, IQR [2.0; 4.0]). CONCLUSION: The learning curve of laparoscopic CME with ICA for right-sided colon cancer demonstrated that 32 cases were needed to obtain a plateau phase expressed by operative time.

Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation.

BACKGROUND: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL. METHOD: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion. RESULTS: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04). CONCLUSION: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04766060.

Robotic vs. TaTME Rectal Surgery (ROTA STUDY) Matched Cohort Trial for Mid to Low Rectal Cancer Surgery Evaluation Trial in the Hands of an Experienced Surgeon.

Background: Recent novel surgical techniques for resection of low rectal cancer have been introduced and these approaches have the potential to overcome anatomical limitations like obesity, narrow male pelvis and bulky and low tumours. Two of these procedures are robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME).Both approaches have distinct advantages and limitations. There has been no head to head trial comparing RLAR and TaTME for patients with mid to low rectal cancer undergoing surgery by experienced surgeons. Previous studies looking at the oncological outcomes of either TaTME or robotic TME included many centres where the surgeons were on a learning curve and hence the true oncological outcomes and clinical benefits can not be measured accurately. Method: The inclusion criteria include experienced surgeons defined as minimum of 60 prior procedures with RLAR or TaTME. Successful oncological and clinical outcomes are defined as circumferential resection margin (CRM) ≥1 mm with limited postoperative morbidity (absence of Clavien-Dindo grade III-IV complications within 30 days after surgery). Local and distal recurrence rates with DFS over 3 years will be measured as primary outcome.Data will be collected prospectively and entered in a dedicated database. Discussion: The primary objective of this study is to conduct a multicentre prospective trial to investigate clinical outcomes, in particular disease free survival (DFS) in patients undergoing RLAR and TaTME. The additional goal is to investigate other efficacy measures, complications rates, health economic aspects and patient reported health related quality of life.This paper describes an important trial conducted in expert centres to establish the needed knowledge for a detailed comparison of outcomes for TaTME versus RLAR.This trial is the first comparative study, comparing TaTME and RLAR, seeking to establish foothold for tailor-made surgical treatment of low rectal cancer patients. Trial registration: The trial is registered in clinicaltrials.gov September 2019. Clinicaltrials.gov id: NCT04200027.

[Vaginal ultrasound scanning causing misdiagnosis of a pregnant patient with hormonal induction of ovulation].

We present the case of a 21-year-old woman who developed a simultaneous extra- and intrauterine pregnancy after hormonal induction of ovulation. The case shows a delay in the detection, relying on usual measures as vaginal ultrasound scanning, of the ectopic pregnancy resulting in peritonealia and an acute laparoscopy. This is a reminder of the increase in the prevalence of heterotopic pregnancies as a result of hormonal induction of ovulation, and indicates that laparoscopy is the gold standard of detecting the cause of abdominal pain including ectopic pregnancy.

[Small bowel perforation following microsurgical diskectomy of lumbar disk prolapse]. / Tyndtarmsperforation som følge af mikrokirurgisk operation for lumbal diskusprolaps.

Intraabdominal lesions after microsurgical discectomy are rare but potentially life threatening. We report a case of a 47-year-old male who developed abdominal pain after discectomy. An abdominal computer tomography demonstrated free air intraperitoneally, and a perforation of the ileum was found by laparotomy. A resection and primary anastomosis was performed. Patients who experience abdominal pain after discectomy should have an acute abdominal computer tomography performed to diagnose any intraabdominal lesions.

[Use of antibiotics in colorectal surgery in Denmark]. / Anvendelse af antibiotika ved kolorektal kirurgi i Danmark.

INTRODUCTION: The aim of the study was to investigate the use of antibiotics in scheduled and acute colorectal surgery in Denmark and on the basis of this and a literature research, to recommend possible antibiotic strategies. MATERIAL AND METHODS: In 2004, a written questionnaire regarding the antibiotic treatment in scheduled operations for colorectal cancer and acute colorectal surgery was submitted to all 39 surgical departments in Denmark which at the time performed colorectal surgical procedures. RESULTS: The response rate was 97%. 17 different antibiotic regimes using five different kinds of drugs were used for antibiotic prophylaxis (AP) in scheduled surgery, and if antibiotic treatment was continued, 20 regimes with six different kinds of drugs were used. In case of faecal contaminations, 76% would continue the antibiotic treatment in planned surgery and 100% in acute surgery. Of these, 17% and 14% respectively were without sufficient aerobe gram-negative coverage after the operation because the treatment with ampicillin or cefuroxime was not continued on the day of the operation. For severe obese patients, 8% of the departments used higher dosage. CONCLUSION: None of the numerous applied antibiotic strategies were inappropriate from a microbiological point of view. However, the combination of metronidazole and ampicillin must be regarded as suboptimal due to a high prevalence of ampicillin resistant Escherichia coli. If the antibiotic treatment is continued after the operation, ampicillin or cefuroxime must be administered again later on the day of the operation. Severe obese patients need higher dosage of antibiotics. The following strategies can be recommended: Cefuroxime plus metronidazol or ampicillin plus gentamicin plus metronidazole.

[Perforation of the intestine after ingestion of magnetic items]. / Tarmperforation efter indtagelse af magnetisk legetøj.

The ingestion of magnetic items is a potentially dangerous condition which may result in local necrosis and perforation of the intestine due to incrustation of the bowel wall between two magnetic bodies. We report a case of a 12-year old girl who ingested several magnetic items, causing perforation of the small intestine. We recommend surgical removal if more than one magnetic foreign body is ingested. If imaging results indicate that only one magnet has been ingested, we recommend a control x-ray within a few hours to confirm a secure passage of the foreign body.