Should Laparoscopic Complete Mesocolic Excision Be Offered to Elderly Patients to Treat Right-Sided Colon Cancer?

BACKGROUND: Despite its potential oncologic benefit, complete mesocolic excision (CME) has rarely been offered to elderly patients. The present study evaluated the effect of age on postoperative outcomes among patients undergoing laparoscopic right colectomies with CME for right-sided colon cancer (RCC). METHODS: Data of patients undergoing laparoscopic right colectomies with CME for RCC between 2015 and 2018 were retrospectively analyzed. Selected patients were divided into two groups: the under-80 group and the over-80 group. Surgical, pathological, and oncological outcomes among the groups were compared. RESULTS: A total of 130 patients were selected (95 in the under-80 group and 35 in the over-80 group). No difference was found between the groups in terms of postoperative outcomes, except for median length of stay and adjuvant chemotherapy received, which were in favor of the under-80 group (5 vs. 8 days, p < 0.001 and 26.3% vs. 2.9%, p = 0.003, respectively). No difference between the groups was found regarding overall survival and disease free survival. Using multivariate analysis, only the ASA score > 2 (p = 0.01) was an independent predictor of overall complications. CONCLUSIONS: laparoscopic right colectomy with CME for RCC was safely performed in elderly patients ensuring similar oncological outcomes compared to younger patients.

Early Postoperative Low Compliance to Enhanced Recovery Pathway in Rectal Cancer Patients.

Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.

Stapled Transanal Rectal Resection (Starr) in the Treatment of Obstructed Defecation: A Systematic Review.

Obstructed defecation syndrome (ODS) is a form of constipation that influences the quality of life in most patients and is an important health care issue. In 2004 Longo introduced a minimal invasive trans-anal approach known as Stapled Trans-Anal Rectal Resection (STARR) in order to correct mechanical disorders such as rectocele or rectal intussusception, two conditions present in more than 90% of patients with ODS. Considering the lack of a common view around ODS and STARR procedure. the aim of our study is to review the literature about preoperative assessment, operative features and outcomes of the STARR technique for the treatment of ODS. We performed a systematic search of literature, between January 2008 and December 2020 and 24 studies were included in this review. The total number of patients treated with STARR procedure was 4,464. In conclusion STARR surgical procedure has been proven to be safe and effective in treating symptoms of ODS and improving patients Quality of Life (QoL) and should be taken in consideration in the context of a holistic and multi modal approach to this complex condition. International guidelines are needed in order to optimize the diagnostic and therapeutic process and to improve outcomes.

Clinical Validation of the Comprehensive Complication Index in Colon Cancer Surgery.

(1) Introduction: To date, the sensitivity of the Comprehensive Complication Index (CCI) in a homogeneous cohort of colonic resections for oncologic purposes has not been reported. The present study aims to compare the CCI with the conventional Clavien-Dindo classification (CDC) in colon cancer patients. (2) Methods: The clinical data of patients submitted to an elective colectomy for adenocarcinoma were retrieved from a prospectively maintained database. Postoperative complications and length of stay were reviewed, and CDC and CCI scores were calculated for each patient. The association of the CCI and the CDC with the length of stay, prolongation of stay and readmission rate were assessed and compared. (3) Results: The overall postoperative morbidity was 26.9%. In particular, 157 (20.4%) patients had more than one complication. A strong correlation between the two scoring systems was observed (r = 99.4%; 95%CI: 99.3-99.5%). In multivariate analysis, CCI had a higher predictive ability for all endpoints. Regarding subgroup analysis, the difference between the CCI and CDC was progressively increased when evaluating outcome measures in complicated and multi-complicated patients. (4) Conclusion: Both scoring systems adequately report the overall burden of postoperative complications. The CCI showed a greater ability than the CDC to predict hospital stay, particularly in patients with multiple postoperative complications.

Is there a role for treatment-oriented surgery in liver metastases from gastric cancer?

BACKGROUND: Distant metastases are found in approximately 35% of patients with gastric cancer at their first clinical observation, and of these, 4%-14% involves the liver. Unfortunately, only 0.4%-2.3% of patients with metastatic gastric cancer are eligible for radical surgery. Although surgical resection for gastric cancer metastases is still debated, there have been changes in recent years, although several clinical issues remain to be defined and that must be taken into account before surgery is proposed. AIM: To analyze the clinicopathological factors related to primary gastric tumor and metastases that impact the survival of patients with liver metastatic gastric cancer. METHODS: We performed a systematic review of the literature from 2000 to 2018 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The study protocol was based on identifying studies with clearly defined purpose, eligibility criteria, methodological analysis, and patient outcome. RESULTS: We selected 47 studies pertaining to the purpose of the review, which involved a total of 2304 patients. Median survival was 7-52.3 mo, median disease-free survival was 4.7-18 mo. The 1-, 2-, 3-, and 5-year overall survival (OS) was 33%-90.1%, 10%-60%, 6%-70.4%, and 0%-40.1%, respectively. Only five papers reported the 10-year OS, which was 5.5%-31.5%. The general recurrence rate was between 55.5% and 96%, and that for hepatic recurrence was between 15% and 94%. CONCLUSION: Serous infiltration and lymph node involvement of the primary cancer indicate an unfavorable prognosis, while the presence of single metastasis or ≤ 3 metastases associated with a size of < 5 cm may be considered data that do not contraindicate liver resection.

Quasi-elective left colectomy after endoscopic colon stenting for obstructive cancer yields comparable oncologic outcome to full-elective operation.

PURPOSE: Whether deferring surgery after endoscopic self-expandable metal stent (SEMS) placement for neoplastic stricture, and operating patients in a quasi-elective situation, may result in similar oncologic outcomes to elective operations is unclear. This study aimed to evaluate the disease-free survival (DFS) rates of patients who underwent an interval colon resection after SEMS placement or an elective operation with comparable cancer stages. METHODS: From a prospective dataset, we retrospectively selected patients with the following characteristics: (1) left-sided colon cancer and (2) cancer stage I to III. Exclusion criteria were as follows: (1) palliative surgery and (2) emergency operation. Then we stratified patients into two groups: (A) full-elective left colon resection and (B) quasi-elective left colon resection, defined as surgery performed after SEMS placement for obstructive colon cancer. DFS function was studied by the Kaplan-Meier method. RESULTS: After 1:2 matching based on cancer stage, 106 patients of the group A were compared with 53 patients of group B. In each group, there were 9.4% of stage I, 39.4% of stage II, and 50.9% of stage III patients. The rate of technical failure in SEMS placement was 3.8%. After a mean follow-up of 54 months, 16 (15.1%) patients in the full-elective groups and 10 (18.9%) in the quasi-elective group experience cancer recurrence (log rank = 0.588). DFS curve did not reach the median value. CONCLUSIONS: SEMS placement with interval colon resection for obstructive neoplastic strictures seems to provide similar long-term oncologic outcomes to operations performed in an elective setting when a low rate of technical failure is achieved.

Value of colpo-cysto-entero defecography to predict the post operative results in patients with obstructed defecation.

INTRODUCTION: The conventional video colpo-cysto entero defecography describing the morpho- functional imaging features, physiological and pathological of the recto-anal region and pelvic floor . It represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions. MATERIALS AND METHODS: Between January 2010 to January 2013 88 patients underwent STARR procedure for obstructed defecation syndrome (ODS) caused by single rectocele or internal rectal intussusception. We retrospectively analyzed the collected data,in particular we reviewed the defecography results before surgery. RESULTS: At defecography imaging , 30 patients (34 %) had an anal canal opening between 0 and 5 seconds, 44 (50 %) between 6 and 10 seconds and 14 patients (16 %) over 10 seconds at defecography imaging. The defecography showed an enterocele in 30 patients (34 %) The enterocele was functional in 25 (28,4 %) and stable in 5 (5,6 %) patients. 53 patients have a II° rectocele (60,2 %) and 35 patients a III° rectocele (39,7 %). The average preoperative ODS score was 14 . The average ODS score revaluated at 1 year was 3.1, 4.3 at 3 years an 6,4 after 5 years. The improvement of the ODS score was lower in the subgroup of patients presenting a slow opening of the anal canal (> 10 sec): 7.5 at one year, 9.1 at 3 years and 11 after 5 years follow-up. Also in the subgroup of patients with stable enterocele (5,6 %) the improvement was less evident: 6.7 at 1 year, 8 at 3 years and 9.7 after 5 years follow-up. DISCUSSION AND CONCLUSION: We have observed that a coexistence of a long opening time of the anal canal and / or the presence of a stable enterocele are factors that significantly reduce the effectiveness of the surgery leading over time to ODS score values close to those present before surgery. In the fisrt case we suggest a pre and post-operative perineal physiotherapy, in the second case a Dougla's platsy KEY WORDS: Defecography, Obstructed defecation syndrome, Rectocele, Recto-anal prolapse.

Treatment of giant condyloma acuminatum of the anus. State of the art.

Giant condyloma acuminatum (GCA) is a rare cauliflower-like lesion, also known as Buschke-L ewenstein tumor (BLT). Although characterized by benign histological features, the local behavior of GCA is extremely aggressive, showing progressive infiltration of the surrounding structures leading to tissue destruction by compression. As the correlation between HPV and GCA development grew stronger, the majority of the Authors came to the conclusion that HPV can not only cause CA but, associated with particular risk factors, it can lead to much more serious conditions such as BLT. Since the treatment of GCA is still not yet standardized, a very accurate pre-operative analysis of the lesions is required to plan the most suitable treatment approach. Based on current knowledge, macroscopic evaluation of local tumor invasion and extensive radical resection appear to be the only valid therapeutic approach, due to its association with longterm survival and minimal recurrence. Looking forward for new techniques and new tissue sparing treatments, at the moment, GCA can be safely treated with radical excision without immediate tissue reconstruction; long-term complications, such as stricture and stenosis, can be prevented by adequate wound healing and by a particularly intense and long- term follow-up program. KEY WORDS: Anus, Giant condyloma acuminatum.

15 years experience in proctological day-surgery.

INTRODUCTION: The actual high hospitalization costs have encouraged a growing attention towards reducing hospital stay. Nowadays, many simple surgical procedures are carried out in a one-day surgery regimen . A shorter hospital stay brings many advantages for the patients: lesser inconvenience, a lower risk of hospital infection and an earlier return to work. In proctology, day surgery polices are still uncommon because surgeons fear possible complications. In this paper we sum up our 15 years experience, stressing the possibility to perform even complex procedures in local-regional anesthesia and in a day-surgery context. MATERIALS AND METHODS: In our experience, to be candidate to one-day surgery proctological procdures, patients should be classed as ASA I or II. RESULTS: Between 2005 and 2015 our operative unit executed a total of 2688 proctological procedures in a one-day surgery. 1062 procedures have been completed under local anesthesia exclusively and all patients have been discharged between two and three hours after the procedure without significant complications. In the other 1626 patients perineal posterior block was performed in 932 cases (57.3%) and provided an optimal pain control in 51,6% of cases (301 patients) while in 5,7% of cases there was the need for an intravenous administration of Fentanil. DISCUSSION AND CONCLUSION: Day-surgery is nowadays a concrete reality, made possible by an attentive selection of patients, an accurate surgical technique, an attentive patient monitoring in the postoperative period and a continuous monitoring of the effectiveness of pain medications. Over the last decades our surgical team has developed modified techniques of loco-regional anesthesia that allow us to perform even complex procedures and discharge the patient within 24 hours. KEY WORDS: Day-surgery, Haemorrhoids, Proctological procedures.

Malignant transformation of a chronic anorectal fistula.

Up to date, only a small number of carcinomas arising from a chronic anorectal fistula have been described in medical literature, especially in patients without Chron's disease. A 72-year-old man with a 6-year history of discharging perianal sinus without Crohn's disease arrived at our institution. He had previously undergone three surgical procedures in other institutions for incision and drainage of recurrent perianal abscesses. Our therapeutical approach was to drain the two abscess cavities, perform a fistulectomy, and biopsy the fistula tissue. Anatomopathological examination of the specimen revealed a mucosecerrnig adenocarcinoma arising from the fistula tract. We decided to perform an abdominal perineal resection. The two-year oncological follow-up is negative. In conclusion, it is clear that the diagnosis of mucinous adenocarcinoma occurring in perianal fistula is difficult, particularly in patients without any risks or predisposing factors. Wide resection of the tumor with Miles's procedure still represents the surgical treatment of choice and may provide a good long term outcome in localized disease KEY WORDS: Cronic anorectal fistula, Malignant transformation, Mucinous adenocarcinoma.

Day-surgery stapled prolassectomy: a "ten minutes job".

INTRODUCTION: Accordingly with the new physiopathologic insights of the 70s and 80s, hemorrhoidal disease appears to originate not much from venous hyperplasia but rather from a progressive deterioration of connective and support tissues with subsequent venous and mucosal prolapse. In the late 90s a new surgical technique for a more physiological treatment of hemorrhoids was introduced: stapled prolassectomy. MATERIALS AND METHODS: Between October 2017 and June 2018 we performed 50 hemorrhoidal stapled prolassectomies under local-regional anesthesia. All patients were classified as ASA I and were aged between 18 and 65 years. Patients were administered Atropine 1 mg and Flunitrazepam 0,7 mg orally 30 minutes prior to the intervention. A topical anesthetic preparation of Lidocaine and Procaine was also applied. A local anesthesia of the anal and perineal region was performed by the surgeon in the presence of an anesthesiologist. RESULTS: Intraoperative pain control was found to be complete and optimal for the majority of patients (92%). Six of the patients (8%) reported mild pain during the stapling phase but did not require further intervention. A conversion to general anesthesia was never required. Forty-four of the patients (88%) were discharged on the same day of the operation. In four cases (9%) discharge was postponed and patients were kept overnight because of early postoperative complications. DISCUSSION AND CONCLUSION: Over 20 years after its introduction, stapled prolassectomy has become the allows to gold standard for treating hemorrhoids. This procedure allows for an effective and appropriate treatment of the condition. It preserve the physiology of the anal channel and to reconstruct the correct topographic relationship between anal derma, anal-rectal mucosa, hemorrhoidal plexus and sphincter apparatus . The absence of surgical wounds in the perineal region allows for a reduced stimulation of pain receptors, leading to a less painful post-operatory course and to a reduced risk of long term complications such as stenotizing scarring and soiling .The use of a mechanic stapler leads to higher costs, but they are in part balanced by the possibility of a faster recovery of patients and of an earlier resumption of work activities. The possibility to perform the operation in day surgery may allow for a global reduction health care expenses leaving more resources available for more complex cases. KEY WORDS: Hemorrhoids, Recto-Anal prolapse, Posterior perineal block.