EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults.

BACKGROUND: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

The ELECLA trial: A multicentre randomised control trial on outcomes of neoadjuvant treatment on locally advanced colon cancer.

BACKGROUND: Colon cancer (CC) is a public health concern with increasing incidence in younger populations. Treatment for locally advanced CC (LACC) involves oncological surgery and adjuvant chemotherapy (AC) to reduce recurrence and improve overall survival (OS). Neoadjuvant chemotherapy (NAC) is a novel approach for the treatment of LACC, and research is underway to explore its potential benefit in terms of survival. This trial will assess the efficacy of NAC in LACC. METHODS: This is a multicentre randomised, parallel-group, open label controlled clinical trial. Participants will be selected based on homogenous inclusion criteria and randomly assigned to two treatment groups: NAC, surgery, and AC or surgery followed by AC. The primary aim of this study is to evaluate the 2-year progression-free survival (PFS), with secondary outcomes including 5-year PFS, 2- and 5-year OS, toxicity, radiological and pathological response, morbidity, and mortality. DISCUSSION: The results of this study will determine whether NAC induces a clinical and histological tumour response in patients with CCLA and if this treatment sequence improves survival without increasing morbidity and mortality. REGISTRATION NUMBER: NCT04188158.

The role of transanal compared to laparoscopic total mesorectal excision (taTME vs. lapTME) for the treatment of mid-low rectal cancer in obese patients: outcomes of a multicenter propensity-matched analysis.

To compare the rate of sphincter-saving interventions between transanal and laparoscopic Total Mesorectal Excision in this particular group of patients. A multicentre observational study was conducted using a prospective database, including patients diagnosed with rectal cancer below the peritoneal reflection and BMI ≥ 30 kg/m2, who underwent minimally invasive elective surgery over a 5-year period. Exclusion criteria were (1) sphincter and/or puborectalis invasion; (2) multi-visceral resections; (3) palliative surgeries. The study population was divided into two groups according to the intervention: transanal or laparoscopic total mesorectal excision. The primary outcome was the rate of sphincter-saving surgery. Secondary outcomes included conversion, postoperative complications, quality of the specimen, and survival. A total of 93 patients were included; 40 (43%) transanal total mesorectal excision were compared to 53 (57%) laparoscopic. In addition, 35 cases of transanal approach were case-matched with an equal number of laparoscopic approaches, based on gender, tumor's height, and neoadjuvant therapy. In both groups, 43% of the patients had low rectal cancer; however, the rate of sphincter-saving surgery was significantly higher in the transanal group (97% vs. 71%, p = 0.003). There were no conversions to open surgery in the transanal group, compared to 2 cases in the laparoscopic group (6%) (p = 0.246). The percentage of major complications was similar, including the rate of anastomotic leakage (10% transanal vs. 19% laparoscopic, p = 0.835). In our experience, higher percentages of sphincter-saving procedures and lower conversion rates are potential benefits of using the transanal approach in a complex surgical setting population of obese patients with mid-low rectal tumors when compared to laparoscopic.

Patient Reported Outcomes following Cancer of the Rectum (PROCaRe): protocol of a prospective multicentre international study.

PURPOSE: Rectal cancer surgery presents challenges in achieving good oncological results and preserving functional outcomes. Different surgical approaches, including open, laparoscopic, robotic and transanal techniques, have been employed, but there is a lack of consensus on the optimal approach, particularly in terms of functional results. This study aims to assess bowel function and to compare outcomes of patients that had undergone surgery for mid-low rectal cancer across different surgical approaches. METHOD: This is an international, multicentre, prospective cohort study. Inclusion criteria are patients diagnosed with rectal cancer below the peritoneal reflection, eligible for different surgical approaches for total mesorectal excision (TME). Data will be collected using validated questionnaires assessing bowel, sexual and urinary function, and quality of life (QOL). Secondary outcomes include short-term postoperative results. Data will be collected at baseline and 6, 12 and 24 months after index surgery or stoma reversal surgery. CONCLUSION: This study will provide insights into the impact of different approaches for TME on bowel, sexual and urinary function, and overall QOL of patients undergoing rectal cancer surgery. The findings will provide important information to optimise the surgical strategy and to improve patient care in this population. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04936581 (registered 23 June 2021).

Management of acute diverticulitis with pericolic free gas (ADIFAS): an international multicenter observational study.

BACKGROUND: There are no specific recommendations regarding the optimal management of this group of patients. The World Society of Emergency Surgery suggested a nonoperative strategy with antibiotic therapy, but this was a weak recommendation. This study aims to identify the optimal management of patients with acute diverticulitis (AD) presenting with pericolic free air with or without pericolic fluid. METHODS: A multicenter, prospective, international study of patients diagnosed with AD and pericolic-free air with or without pericolic free fluid at a computed tomography (CT) scan between May 2020 and June 2021 was included. Patients were excluded if they had intra-abdominal distant free air, an abscess, generalized peritonitis, or less than a 1-year follow-up. The primary outcome was the rate of failure of nonoperative management within the index admission. Secondary outcomes included the rate of failure of nonoperative management within the first year and risk factors for failure. RESULTS: A total of 810 patients were recruited across 69 European and South American centers; 744 patients (92%) were treated nonoperatively, and 66 (8%) underwent immediate surgery. Baseline characteristics were similar between groups. Hinchey II-IV on diagnostic imaging was the only independent risk factor for surgical intervention during index admission (odds ratios: 12.5, 95% CI: 2.4-64, P =0.003). Among patients treated nonoperatively, at index admission, 697 (94%) patients were discharged without any complications, 35 (4.7%) required emergency surgery, and 12 (1.6%) percutaneous drainage. Free pericolic fluid on CT scan was associated with a higher risk of failure of nonoperative management (odds ratios: 4.9, 95% CI: 1.2-19.9, P =0.023), with 88% of success compared to 96% without free fluid ( P <0.001). The rate of treatment failure with nonoperative management during the first year of follow-up was 16.5%. CONCLUSION: Patients with AD presenting with pericolic free gas can be successfully managed nonoperatively in the vast majority of cases. Patients with both free pericolic gas and free pericolic fluid on a CT scan are at a higher risk of failing nonoperative management and require closer observation.

Robotic surgery for locally advanced T4 rectal cancer: feasibility and oncological quality.

For T4 rectal tumours and local recurrences (LR) of rectal cancer, a radical resection beyond TME, sometimes by multi-visceral resection, is important to obtain safe margins and improve survival. The use of the laparoscopic approach (LA) for these cases is still controversial and associated with a high rate of conversion. However, robotic surgery might offer some advantages that can overcome some of the limitations of LA. Therefore, we aimed to analyse the postoperative outcomes and medium-term oncological results of robotic surgery for locally advanced rectal cancer (pathological T4) and LR. A retrospective analysis was performed including patients who had undergone robotic rectal resection in a single institution over an 11-year period, and had a T4 tumour confirmed in the pathological report. Primary endpoint was to analyse postoperative complications (30-day) and the rate of conversion. Secondary endpoints include pathological assessment of the quality of the specimen, local recurrence and survival [2-year disease-free survival (DFS) and overall survival (OS)]. A total of 41 patients were analysed, including a total of 24 patients (60%) that required a multivisceral resection. The median distance from the tumour to the anorectal junction was 7 (4-12) cm. Conversion to open surgery was necessary in 2 cases (5%). The overall morbidity rate was 78% (n = 32), with 37% of major complications, most of them urinary (n = 7). Median length of hospital stay (LOS) was 13 (7-27) days. The 30-day mortality rate was 7% (n = 3). An R0 resection was achieved in 85.4% of the cases (n = 35) due to 6 cases of the positive circumferential resection margin. 2-year disease-free survival (DFS) and overall survival (OS) for the T4 tumours were 72% and 85%, respectively. There were 8 cases of local recurrence (22.2%); 6 of them met the selection criteria for salvage surgery. Robotic surgery for locally advanced T4 rectal cancer and multi-visceral resections is safe and feasible, with a low rate of conversion and an acceptable rate of postoperative morbidity in this subgroup of patients. Oncological results have shown to be comparable with the laparoscopic series published, preserving a good quality of the resected specimen. However, comparative studies and a longer follow-up period is needed to confirm the oncologic findings and to support the general adoption of the robotic system for these complex interventions.

Surgical education in the post-COVID era: an EAES DELPHI-study.

BACKGROUNDS: To date, it is unclear what the educational response to the restrictions on minimally invasive surgery imposed by the COVID-19 pandemic have been, and how MIS-surgeons see the post-pandemic future of surgical education. Using a modified Delphi-methodology, this study aims to assess the effects of COVID on MIS-training and to develop a consensus on the educational response to the pandemic. METHODS: A three-part Delphi study was performed among the membership of the European Association of Endoscopic Surgery (EAES). The first survey aimed to survey participants on the educational response in four educational components: training in the operating room (OR), wet lab and dry lab training, assessment and accreditation, and use of digital resources. The second and third survey aimed to formulate and achieve consensus on statements on, and resources in, response to the pandemic and in post-pandemic MIS surgery. RESULTS: Over 247 EAES members participated in the three rounds of this Delphi survey. MIS-training decreased by 35.6-55.6%, alternatives were introduced in 14.7-32.2% of respondents, and these alternatives compensated for 32.2-43.2% of missed training. OR-training and assessments were most often affected due to the cancellation of elective cases (80.7%, and 73.8% affected, respectively). Consensus was achieved on 13 statements. Although digital resources were deemed valuable alternatives for OR-training and skills assessments, face-to-face resources were preferred. Videos and hands-on training-wet labs, dry labs, and virtual reality (VR) simulation-were the best appreciated resources. CONCLUSIONS: COVID-19 has severely affected surgical training opportunities for minimally invasive surgery. Face-to-face training remains the preferred training method, although digital and remote training resources are believed to be valuable additions to the training palette. Organizations such as the EAES are encouraged to support surgical educators in implementing these resources. Insights from this Delphi can guide (inter)national governing training bodies and hospitals in shaping surgical resident curricula in post pandemic times.

The INTESTINE study: INtended TEmporary STomas In crohN's diseasE. Protocol for an international multicentre study.

Surgery for ileocolonic Crohn's disease can result in temporary or permanent stoma formation which can be associated with morbidity as parastomal and incisional hernias, readmissions due to obstruction or high stoma output, and have a negative impact on quality of life. We propose an international retrospective trainee-led study of the outcomes of temporary stomas in patients with Crohn's disease. We aim to evaluate both the short-term (6 month) and mid-term (18 month) outcomes of temporary stomas in patients with Crohn's Disease. Retrospective, multicentre, observational study including all patients who underwent elective or emergency surgery for ileal, colonic and ileocolonic Crohn's disease during a 4-year study period. Primary outcome is the proportion of patients who still have an ileostomy or colostomy 18 months after the initial surgery. Secondary outcomes: complications related to stoma formation and stoma reversal surgery; time interval between stoma formation and stoma reversal; risk factors for stoma formation and non-reversal of the stoma. We present the study protocol for a trainee-led, multicentre, observational study. Previous research has demonstrated significant heterogeneity surrounding the formation and the timing of reversal surgery in patients having a temporary ileostomy following colorectal cancer surgery, highlighting the need to address these same questions in Crohn's disease, which is the aim of our research.

Consensus statements on complete mesocolic excision for right-sided colon cancer-technical steps and training implications.

BACKGROUND: CME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways. METHODS: Guidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus. RESULTS: Twenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme. CONCLUSIONS: Consensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies.

Robotic oncologic colorectal surgery with a new robotic platform (CMR Versius): hope or hype? A preliminary experience from a full-robotic case-series.

BACKGROUND: The present case-series describes the first full-robotic colorectal resections performed with the new CMR Versius platform (Cambridge Medical Robotics Surgical, 1 Evolution Business Park, Cambridge, United Kingdom) by an experienced robotic surgeon. METHODS: In a period between July 2020 and December 2020, patients aged 18 years or older, who were diagnosed with colorectal cancer and were fit for minimally invasive surgery, underwent robotic colorectal resection with CMR Versius robotic platform at "Casa di Cura Cobellis" in Vallo della Lucania,Salerno, Italy. Three right colectomies, 2 sigmoid colectomies and 1 anterior rectal resection were performed. All the procedures were planned as fully robotic. Surgical data were retrospectively reviewed from a prospectively collected database. RESULTS: Four patients were male and 2 patients were female with a median (range) age of 66 (47-72) years. One covering ileostomy was created. Full robotic splenic flexure mobilization was performed. No additional laparoscopic gestures or procedures were performed in this series except for clipping and stapling which were performed by the assistant surgeon due to the absence of robotic dedicated instruments. Two ileocolic anastomoses, planned as robotic-sewn, were performed extracorporeally. One Clavien-Dindo II complication occurred due to a postoperative blood transfusion. Median total operative time was 160 (145-294) min for right colectomies, 246 (191-300) min for sigmoid colectomies and 250 min for the anterior rectal resection. CONCLUSIONS: The present series confirms the feasibility of full-robotic colorectal resections while highlighting the strengths and the limitations of the CMR Versius platform in colorectal surgery. New devices will need more clinical development to be comparable to the current standard.

How to perform an anastomosis following a low anterior resection by transanal total mesorectal excision surgery: from top to bottom techniques.

AIM: The aim was to describe the range of possibilities and our group's clinical outcomes when performing different types of anastomosis during transanal total mesorectal excision (taTME). METHOD: A retrospective analysis was performed based on four taTME series from 2016 to 2021. Inclusion criteria were patients with rectal cancer in whom a sphincter-saving low anterior resection by taTME was performed. Four different techniques were employed for the anastomosis construction: (A) abdominal view, (B) transanal view, (C) hand-sewn coloanal anastomosis and (D) pull-through. Intra-operative and postoperative data were collected and compared. RESULTS: A total of 161 patients were included. Tumour height was lower in groups C and D (4 [3-5] vs. 7 [6-8] group A vs. 6 [5-7] group B, P = 0.000), requiring a hand-sewn anastomosis. A transanal extraction of the specimen was more commonly performed in groups C and D (over 60% vs. 30% in groups A and B, P = 0.000). The rate of temporary stoma was similar between groups A, B and C (ranging from 84% to 98%) but was significantly lower in group D (P = 0.000). The overall rate of complications was similar between groups; however, group D had longer length of stay (15 days vs. 5-6 in groups A, B and C, P = 0.026). CONCLUSION: Every type of anastomosis construction after a taTME procedure seems to be safe and feasible and should be chosen based on surgeon's experience, tumour height and the length of the rectal cuff after the rectal transection. Colorectal surgeons should be familiar with these techniques in order to choose the one that benefits each patient the most.