Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement.

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Does Obesity Impact Surgical and Pathological Outcomes in Robotic Complete Mesocolic Excision for Colon Cancer?

Background: Obesity is one of the contributing factors to technical difficulties in minimally invasive colorectal surgery. However, there are no data regarding the outcomes for obese patients undergoing robotic complete mesocolic excision (CME) for colon cancer. In this study, we aimed to investigate whether robotic CME in obese patients can be performed with similar morbidity and pathological results compared with nonobese patients. Methods: Patients who underwent robotic CME between 2014 and 2019 were classified into obese and nonobese groups. Obesity was defined as body mass index ≥30 kg/m2. Demographic data, perioperative outcomes and pathological results were compared between the groups. Results: There were 42 and 105 patients in the obese and nonobese group, respectively. The groups were comparable regarding preoperative characteristics. There were no significant differences with respect to operative times (244 ± 64 versus 304 ± 75 minutes, P = .29), blood loss (median, 50 versus 80 mL, P = .20), intraoperative complications (0% versus 3.8%, P > .99), and conversions (0% versus 1.9%, P > .99). No differences were detected in length of hospital stay (6 ± 1 versus 6 ± 2 days, P = .73), anastomotic leak (2.4% versus 1.9%, P > .99), septic complications, reoperations (2.4% versus 3.8%), and readmissions (2.4% versus 2.9%) (P > .05). The mean number of harvested lymph nodes (33 ± 11 versus 34 ± 13, P = .79), resection margin status, and mesocolic fascia grading were similar. Conclusion: Robotic CME in obese patients can be performed with a similar morbidity and pathological profile compared with nonobese patients. The Clinical Trial Registration number is not applicable for this study.

Metastasis to lymph nodes around the vascular tie worsens long-term oncological outcomes following complete mesocolic excision and conventional colectomy for right-sided colon cancer.

BACKGROUND: Oncologic outcomes after complete mesocolic excision (CME) in colon cancer are under investigation. The aim of our study was to compare CME and conventional colectomy (CC) in terms of pathological and oncological outcomes for right colon cancer and to evaluate the impact of lymph node metastasis around the vascular tie on survival. METHODS: Consecutive patients with right colon cancer who had CME or CC between January 2011 and August 2018 at two specialized centers in Turkey were included. Statistical analyses were performed with respect to demographic characteristics, operative and pathologic outcomes, harvested and metastatic lymph nodes around the vascular tie (LNVT), recurrences, and survival. RESULTS: There were 91 patients in the CME group (58 males, mean age 64 ± 16 years) and 192 patients in the CC group (96 males, mean age 66 ± 14 years). The mean number of harvested lymph nodes (CME: 42 ± 15 vs CC: 34 ± 13, p = 0.01) and LNVT were higher in the CME group (CME: 3.2 ± 2.2 vs CC: 2.4 ± 1.6, p = 0.001). LNVT metastases were 7.7% and 8.3% in the CME and CC groups, respectively (p = 0.85). Three-year overall and disease-free survival rates were 96.4% and 90.9% in the CME group and 90.4% and 87.6% in the CC group in stage I-III patients (p > 0.05). In stage III patients, the 3-year overall survival (92.5% vs 63.5%, p = 0.03) and disease-free survival (85.6% vs 52.1%, p = 0.008) were significantly better in LNVT-negative patients than in LNVT-positive patients. CONCLUSION: LNVT metastasis seems to be the key factor associated with poor disease-free and overall survival in right colon cancer regardless of the radicality of surgery.

Minimally invasive versus open surgery for gastric cancer in Turkish population.

Objectives: In this study, it was aimed to compare short-term outcomes of minimally invasive and open surgery for gastric cancer in the Turkish population carrying both European and Asian characteristics. Material and Methods: Short-term (30-day) outcomes of the patients undergoing minimally invasive and open gastrectomy with D2 lymphadenec- tomy for gastric adenocarcinoma between January 2013 and December 2017 were compared. Patient demographics, history of previous abdominal surgery, comorbidities, short-term perioperative outcomes and histopathological results were evaluated between the study groups. Results: There were a total of 179 patients. Fifty (28%) patients underwent minimally invasive [laparoscopic (n= 19) and robotic (n= 31)] and 129 (72%) patients underwent open surgery. There were no differences between the two groups in terms of age, sex, body mass index and ASA scores. While operative time was significantly longer in the minimally invasive surgery group (p <0.0001), length of hospital stay and operative morbidity were com- parable between the groups. Conclusion: While both laparoscopic and robotic surgery is safe and feasible in terms of short-term outcomes in selected patients, long operating time and increased cost are the major drawbacks of the robotic technique preventing its widespread use.

Learning curve analysis of robotic transabdominal preperitoneal inguinal hernia repair.

BACKGROUND: The purpose of this study was to assess the learning curve (LC) for inguinal hernia repair with robotic transabdominal preperitoneal (R-TAPP) approach. METHODS: Between April 2016 and October 2019, patients who underwent R-TAPP were retrieved. Patient demographics, operative variables and postoperative outcomes were assessed. The moving average method and cumulative sum of operation times (OT) were used to evaluate the LC. The surgeon (BB) in this study had completed his laparoscopic (Lap) TAPP experience. RESULTS: There were 50 (two females) consecutive patients (mean age was 51.7 ± 16.9 years). The first phase (learning phase) included initial 35 operations. The second phase included the next 15 operations. It was observed that, with increasing experience, a statistically significant shortening in the average OT by about 25 min was achieved (p = 0.041). CONCLUSION: The LC phase for R-TAPP, for surgeon with previous experience in Lap TAPP, seems to be very quick without compromising the operative morbidity.

Operative and long-term oncological outcomes in patients undergoing robotic versus laparoscopic surgery for rectal cancer.

BACKGROUND: This study aimed to compare short- and long-term outcomes after robotic versus laparoscopic approach in patients undergoing curative surgery for rectal cancer. METHODS: Patients undergoing elective robotic and laparoscopic resection for rectal cancer were included. Perioperative clinical characteristics, postoperative short- and long-term outcomes were compared between groups. RESULTS: There were 72 and 44 patients in robotic (RG) and laparoscopic (LG) groups respectively. No differences were detected regarding patients' demographics, histopathologic outcomes, conversion rates and 30-day overall postoperative complication rates. Operative time was longer in the RG (341 ± 111.7 vs. 263 ± 97.5 min, p = 0.001) and length of stay was longer in the LG (4.4 ± 1.9 vs. 6.4 ± 2.9 days, p = 0.001). The 5-year overall and disease-free survival rates were similar (97.1% and 94.9%, p = 0.78; 86.2% and 82.7%, p = 0.72) between the groups. CONCLUSION: This study showed both short and long-term outcomes of a limited number of included patients between the robotic and laparoscopic surgery were similar. However, future studies and randomized trials are necessary to establish these findings.

Totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma.

BACKGROUND: Data regarding the outcomes of pure minimally invasive techniques of radical gastrectomy are scarce. We aimed to compare short-term post-operative outcomes in patients undergoing totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma. METHODS: Between December 2013 and March 2018, robotic and laparoscopic radical gastrectomy performed in two centres were included. Both groups were compared with respect to perioperative short-term outcomes. RESULTS: Ninety-four patients were included in the study. Anticoagulant and neoadjuvant chemotherapy use were higher in the robotic group (p = 0.02, p = 0.02). There were conversions in the laparoscopy group whereas no conversions occurred in the robotic group (p = 0.052). Operating time in the robotic group was longer (p = 0.001). The number of harvested lymph nodes in the laparoscopic group was higher (p = 0.047). CONCLUSION: Totally robotic technique with the da Vinci Xi® robotic system provides similar short-term results compared to laparoscopic surgery in radical gastrectomy.

Impact of Prolonged Neoadjuvant Treatment-surgery Interval on Histopathologic and Operative Outcomes in Patients Undergoing Total Mesorectal Excision for Locally Advanced Rectal Cancer.

BACKGROUND: This study primarily aimed to assess the impact of prolonged neoadjuvant treatment-surgery interval (PNSI) on histopathologic and postoperative outcomes. Impacts of the mode of neoadjuvant treatment (NT) and surgery on the outcomes were also evaluated in the same patient population. PATIENTS AND METHODS: Between February 2011 and December 2017, patients who underwent NT and total mesorectal excision for locally advanced rectal cancer were included. PNSI was defined as >4 and >8 weeks after short-course and long-course NT modalities, respectively. RESULTS: A total of 44 (27%) patients received short-course NT (standard interval: n=28; PNSI: n=16) and 122 (73%) patients received long-course NT (standard interval: n=39; PNSI: n=83). Postoperative morbidity was similar between the standard interval and PNSI in patients undergoing short-course [n=3 (11%) vs. n=3 (19%), P=0.455] and long-course [n=6 (15%) vs. n=16 (19%), P=0.602] NT. PNSI was associated with increased complete pathologic response in patients receiving short-course NT [0 vs. n=5 (31%), P=0.002]. Compared with short-course NT, long-course NT was superior in terms of tumor response based on the Mandard [Mandard 1 to 2: n=6 (21%) vs. 6 (38%), P=0.012] and the College of American Pathologists (CAP) [CAP 0 to 1: n=13 (46%) vs. n=8 (50%), P=0.009] scores. Postoperative morbidity was similar after open, laparoscopic, and robotic total mesorectal excision [n=1 (14.2%) vs. n=21 (21%) vs. n=6 (12.5%), P=0.455] irrespective of the interval time to surgery and the type of NT. CONCLUSIONS: PNSI can be considered in patients undergoing short-course NT due to its potential oncological benefits. The mode of surgery performed at tertiary centers has no impact on postoperative morbidity after both NT modalities.

Predictors of endoscopic recurrence in resected patients with Crohn's disease in a long-term follow-up cohort: History of multiple previous resections and residual synchronous disease in the remnant intestine.

BACKGROUND/AIMS: This study aimed to determine the predictors of endoscopic recurrence in a cohort of patients with Crohn's disease (CD) with prior intestinal resections. MATERIALS AND METHODS: The charts of the patients with CD were reviewed in a retrospective manner. Eighty-three patients were eligible for the final analysis. Demographic features of these patients and time between resection and colonoscopy, presence of any macroscopic residual disease in the remnant intestine, and postoperative medications were noted. Rutgeerts score was used to define postoperative endoscopic recurrence. RESULTS: The patients' mean age±SD at their final colonoscopy was 42.81±11.99 yr; and 37 of 83 patients (45%) were female. The mean follow-up time between resection and the final colonoscopy was 51.16±51.08 months. A total of 51 of 83 patients (61%) were in endoscopic remission (i0, i1); whereas 32 (39%) had an endoscopic recurrence (i2, i3, i4). History of multiple resections (χ2=6.12; p=0.013) and the presence of any postoperative residual disease in the remnant intestine (χ2=5.86; p=0.015) were risk factors; whereas the regular use of azathioprine (AZA) was significantly more common among patients without recurrence (χ2=4.515; p=0.034). In an age-sex adjusted Cox regression analysis history of multiple resections, presence of any postoperative residual disease proved to be independent risk factor for endoscopic recurrence, whereas the regular use of AZA proved to be ineffective. CONCLUSION: In a retrospective long-term follow-up cohort of resected patients with CD, having multiple resections for CD and the presence of any residual synchronous disease after ileocolonic resection were identified as risk factors for endoscopic recurrence; the latter was never reported in previous studies.

Live surgical demonstrations for minimally invasive colorectal training.

PURPOSE: Live surgical demonstrations are considered an effective educational tool providing a chance for trainees to observe a real-time decision-making process of expert surgeons. No data exists evaluating the impact of live surgical demonstrations on the outcomes of minimally invasive colorectal surgery. This study evaluates perioperative and short-term postoperative outcomes in patients undergoing minimally invasive colorectal surgery in the setting of live surgical demonstrations. METHODS: Patients undergoing minimally invasive colorectal surgery which was performed as live surgical demonstrations (the study group) performed between 2006 and 2018 were reviewed. These patients were case-matched with those undergoing operations in routine practice (the control group). The study and control group were compared for intraoperative and short-term postoperative outcomes. RESULTS: Thirty-nine live surgery cases in the study group were case-matched with its thirty-nine counterparts as the control group. Operating time was longer (200 vs 165 min; p = 0.002) and estimated intraoperative blood loss was higher in the study group (100 vs 55 ml; p = 0.008). Patients in the study group stayed longer in the hospital (6 vs 5 days; p = 0.001). While conversion (n = 4 vs n = 1, p = 0.358) and intraoperative complications (n = 6 vs n = 2, p = 0.2) were more frequent in the study group, these outcomes did not reach statistical significance. Overall complications were higher in the study group (n = 22 vs n = 9, p = 0.003). One patient underwent a reoperation due to postoperative bleeding, and one mortality occurred in the live surgery group. CONCLUSIONS: Live surgical demonstrations in minimally invasive colorectal surgery seem to be associated with increased risk of operative morbidity.

Management of Complicated Ostomy Dehiscence: A Case Study.

BACKGROUND: Stoma creation is a common procedure in colorectal surgery. Despite improved surgical techniques, ostomy-related wound complications may prolong the recovery period and impair health-related quality of life. Negative pressure wound therapy (NPWT), autolytic debridement agents, and silver dressings are often used for managing complex wound infection and dehiscence. These applications have the potential to increase patient comfort and accelerate recovery. CASE: We report our experience in a 66 year old female who had a wound dehiscence involving the ostomy after robotic abdominoperineal resection. Her medical history was significant for a rectovaginal fistula which occurred after a low anterior resection for rectal cancer 5 years ago. Interventions for treatment of the dehiscence were use of NPWT, autolytic debriding agent, and silver dressing. CONCLUSION: Combined use of these interventions for dehiscence of an ostomy can minimize patient discomfort and accelerate wound healing.

Short-term Results After Totally Robotic Restorative Total Proctocolectomy With Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

In this study, we aimed to present our initial experience on totally robotic total restorative proctocolectomy in ulcerative colitis (UC) patients. Patients undergoing a totally robotic restorative total proctocolectomy with ileal J-pouch anal anastomosis for UC between January 2015 and November 2017 were included. The da Vinci Xi was used for the operations. Patient demographics, perioperative and short-term operative outcomes were evaluated. Ten patients were included. The median operative time was 380 minutes(range, 300 to 480 min). The median blood loss was 65 mL (range, 5 to 400 mL). No conversion to open surgery was needed. The median time to flatus was 1 day (range, 1 to 2) and length of stay was 6 (4 to 12) days. Short-term complications (≤30 d) were superficial wound infection (n=3), anal bleeding (n=1), pouchitis (n=1). No mortality was observed during the study period. Our study, which is the largest series so far, reveals that totally robotic restorative proctocolectomy is a safe and feasible option for the surgical treatment of UC.

Totally laparoscopic and totally robotic surgery in patients with left-sided colonic diverticulitis.

BACKGROUND: Introduction of the da Vinci Xi system has facilitated the use of robotics in colorectal surgery. Nevertheless, data on the outcomes of robotic surgery for the treatment of colonic diverticulitis have remained scarce. METHODS: Patient demographics, clinical characteristics, and perioperative outcomes of the patients undergoing totally robotic with the da Vinci Xi system or laparoscopic surgery for left-sided colonic diverticulitis (LCD) were compared. RESULTS: Laparoscopic and robotic groups included 22 and 20 patients, respectively. There were no significant differences between the two groups in terms of patient demographics, clinical characteristics, operative time, and postoperative complications. There were three conversions in the laparoscopy group and no conversion in the robotic group (P = 0.23). Conversion to open surgery was associated with postoperative morbidity (P = 0.02). CONCLUSION: Robotic surgery is an applicable alternative for the treatment of LCD. Robotic approach may potentially lower the risk of operative morbidity by reducing the requirement of conversion.

Fully robotic total gastrectomy with D2 lymphadenectomy for gastric cancer.

PURPOSE: Robotic surgery with technical advantages was shown to make complex maneuvers easier and more precise for gastric surgery [1]. This video demonstrates our technique on robotic total gastrectomy with the da Vinci Xi platform for gastric cancer. METHODS: 68-year-old female was presented with persistent epigastric abdominal pain and underwent upper endoscopy showed ulcerated mass extended from the cardia to the lesser curvature. Histopathology showed gastric adenocarcinoma. After patient received neoadjuvant chemotherapy, decision was made to proceed with surgery. RESULTS: Initially, greater curvature dissection was started by division of the gastrocolic ligament with entering the lesser sac with monopolar scissors and bipolar forceps. The right gastroomental vessels were identified and divided at their root along with lymph nodes. After ligation of the right gastric vessels, dissection was extended to retrieve lymph nodes around the left gastric vessels. Duodenum was circumferentially dissected and transected 2 cm distal to the pylorus. Subsequently, extended lymphadenectomy was started with suprapancreatic lymph node dissection to retrieve lymph nodes around the common hepatic artery and celiac axis. Spleen-preserving dissection of the lymphatic tissue of the distal splenic artery and the splenic hilum was performed. The distal esophagus was divided with robotic stapler. Fully robotic end-to-side esophagojejunal anastomosis was constructed. For the reconstruction of gastrointestinal continuity after total gastrectomy, side-to-side jejuno-jejunal anastomosis was performed. Total operative time was 5 hours and estimated blood loss was 20 cc. DISCUSSION: Totally robotic gastrectomy with D2-lymphadenectomy is a safe technique for gastric cancer and provides intracorporeal suturing in reconstructing the anatomy.