Colorectal Surgery
Section Editor: Roberto C.M. Bergamaschi, MD, PhD, FRCS (Engl), FASCRS, FACS
PREFACE by Antonio Longo, MD
Blind Colostomy: The Case Against
Editorial
Mahir Gachabayov, MD, PhD, Research Scholar, New York Medical College, Westchester Medical Center, Valhalla, NY, Mirkhalig Javadov, MD, Attending Surgeon, Yeditepe University Hospital, Istanbul, Turkey, Roberto Bergamaschi, MD, PhD, FRCS, FACS, FASCRS, Professor and Chief, New York Medical College, Westchester Medical Center, Valhalla, NY
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Meta-Analysis of the Impact of the Learning Curve in Robotic Rectal Cancer Surgery on Histopathologic Outcomes
Mahir Gachabayov, MD, PhD, Research Scholar, Roberto Bergamaschi, MD, PhD, Professor of Surgery and Chief, New York Medical College, Westchester Medical Center, Valhalla, NY, Karen You, BS, Research Assistant, State University of New York, Stony Brook, NY, Seon-Hahn Kim, MD, PhD, Professor of Surgery, Director of Cancer Center, Korea University Anam Hospital, Seoul, Korea, Tomohiro Yamaguchi, MD, PhD, Head, Shizuoka Cancer Center Hospital, Shizuoka, Japan, Rosa Jimenez-Rodriguez, MD, PhD, Associate Head, Hospital Universitario Virgen del Rocio, Sevilla, Spain, Li-Jen Kuo, MD, Head, Division of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan, Fabio Cianchi, MD, PhD, Professor and Chief, University of Florence, Florence, Italy, Fabio Staderini, MD, Surgery Resident, University of Florence, Florence, Italy
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Introduction: Although the process of learning robotic surgery for rectal cancer is associated with a prolonged operating time and higher complication rates, its impact on histopathologic outcomes is unknown. The aim of this meta-analysis was to evaluate the impact of the learning curve in robotic surgery for rectal cancer on histopathologic outcomes.
Methods: The PubMed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL, and Web of Science databases were systematically searched. The inclusion criterion was any clinical study comparing the outcomes of robotic surgery for rectal cancer between different phases of the learning curve (LC) including competence (C). The primary endpoint was the circumferential resection margin (CRM) involvement rate defined as CRM £1 mm. The Mantel-Haenszel method with odds ratios with 95% confidence intervals (OR (95%CI)) was used for dichotomous variables.
Results: Ten studies including a total of 907 patients (521 LC and 386 C) were selected. Nine studies were found to have a low risk of bias, and one had a moderate risk of bias. The CRM involvement rate was 2.9% (13/441) for learning curve vs. 4.6% (13/284) for competence. This difference was not significant (OR (95%CI) = 0.70 (0.30, 1.60); p=0.39; I2=0%).
Conclusion: A surgeon’s learning curve seems to have no impact on CRM involvement rates compared to surgeon competence in robotic surgery for rectal cancer.
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Enterocele Reduction in the Prone Position: New Horizons for Safer Stapled Transanal Rectal Resections
Sandra Maria Moreira Paim, MD, FBSCP, Researcher, Colon and Rectal Surgeon, Melinda Hawkins, MD, Resident, Maryellyn Gilfeather, MD, FACR, Radiologist, John Griffin, MD, FACS, FASCRS, Program Director of the St. Mark’s Colon and Rectal Surgery Residency Program, Department of Colon and Rectal Surgery, St. Mark’s Hospital, Salt Lake City
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Aim: The presence of enterocele may interfere with the surgical approach for obstructed defecation syndrome (ODS) as it may represent a contraindication to stapled transanal rectal resection (STARR), and tactics to overcome this problem have been debated. A change in the patient’s position during surgery may be a means to overcome an enterocele. We sought to determine whether an enterocele could be completely reduced when the patient is placed in the prone position during fluoroscopic defecography (FD).
Methods: Patients of a Colon and Rectal Surgery Residency Program undergoing FD for any condition from August 2012 to May 2016 were enrolled. For participants with an enterocele documented during FD, projections in the prone position were also obtained. Data regarding sex, age, pelvic floor laxity, rectocele, intussusception, sigmoidocele, enterocele and its reduction in the prone position were recorded for all participants. Enterocele reduction was analyzed by Fisher’s exact test.
Results: A total of 101 patients were enrolled and an enterocele was found in 63 (62.3%). Among the patients with an enterocele, in 48 (76.2%) it was completely reduced when the patient was placed in the prone position (p-value = 0.000195; 95% CI 63.79 - 86.02).
Conclusion: Complete enterocele reduction in the prone position during FD was highly statistically significant. This finding may safely eliminate enterocele as a contraindication to STARR. These results suggest that a projection in the prone position should be added to the standard sequence obtained during FD for patients who may be eligible for a transanal surgical approach. Validation studies are needed to assess whether this change can lead to lower enterocele-related complications in STARR.
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Tying and Tearing in Robotic and Laparoscopic Intracorporeally Hand-Sewn Ileocolic Anastomoses. A Propensity Score-Matched Prospective Study
Mahir Gachabayov, MD, PhD, Research Fellow, George Angelos, MD, Attending Colorectal Surgeon, Division of Colon and Rectal Surgery, Roberto Bergamaschi, MD, PhD, FRCS, FASCRS, FACS, Chief, Professor of Surgery, Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY34/1087
Aim: The aim of this study was to evaluate the impact of the ergonomics of laparoscopy as well as the lack of tactile feedback in robotic surgery on intracorporeal suturing.
Methods: This was a prospective cohort study that compared the first 12 consecutive robotic hand-sewn ileocolic anastomoses to matched laparoscopic cases performed by the same surgeon. The endpoints were interrupted suturing and tying time, and the numbers of interrupted sutures placed and torn. Propensity score matching was based on age, body mass index, previous abdominal surgery, and diagnosis. Ileocolic anastomoses were hand-sewn in two layers: running 3-0 polyglycolic acid and interrupted 3-0 silk. Continuous variables were compared using the Student t test, whereas a Chi-square test was used to compare categorical variables. Linear regression and a cumulative sum analysis (CUSUM) were used for quality control.
Results: Median time for robotic suturing and tying was significantly shorter than that in matched laparoscopic cases (89.5 sec (IQR 76-103.5) vs. 160 sec (IQR 146-210), p<0.0001). There were fewer torn sutures in laparoscopic suturing (1 (IQR 1-2.5) vs. 0 (IQR 0-0.5), p<0.0026). No differences were found in complication rates (6 vs. 2 p=0.19). CUSUM analysis did not show a significant improvement in the number of torn sutures over time.
Conclusion: Although there were more torn sutures with robotic suturing and tying, significantly less time was required than for laparoscopic intracorporeal suturing. This study suggests that torn sutures may be the result of a lack of tactile feedback rather than the presence of a learning curve.
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Splenic Flexure Mobilization in Sigmoid and Rectal Resections: A Systematic Review and Meta-Analysis of Observational Studies
Mahir Gachabayov, MD, PhD, Research Scholar, Roberto Bergamaschi, MD, PhD, FRCS, FACS, FASCRS, Professor and Chief, Westchester, Medical Center, New York Medical College, Valhalla, NY, Luigi Boni, MD, FACS, Chief, Department of Surgery, Fondazione IRCCS, Ca’ Granda - Ospedale Maggiore Policlinico, University of Milan, Milan, Italy, Selman Uranues, MD, FACS, Professor and Head, Abe Fingerhut, MD, FACS, FRCPS (G), FRCS (Ed)(Hon), Professor of Surgery, Medical University of Graz, Graz, Austria
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Objective: There is no consensus regarding whether splenic flexure mobilization (SFM) should be performed selectively or routinely for sigmoid and rectal resections. The aim of this study was to evaluate the impact of SFM on anastomotic leak and surgical site infection rates in sigmoid and rectal resections.
Methods: PubMed, MEDLINE, EMBASE, Cochrane Library, and Scopus databases were searched by two independent researchers. Anastomotic leak was the primary endpoint. Inclusion criteria were clinical studies comparing SFM to non-SFM during sigmoid and rectal resections. The Mantel-Haenszel method with a random-effects model was used. The odds ratio (OR) was used for dichotomous variables, whereas the mean difference (MD) was used for continuous variables.
Results: Six of 74 potentially eligible studies totaling 12,398 patients (4,356 with SFM and 8,042 without SFM) were selected for further examination. The overall bias risk was found to be high. There was no significant difference in anastomotic leak rates when SFM patients were compared to their non-SFM counterparts [OR (95%CI) = 2.00 (0.95, 4.18); p=0.07]. SFM patients had a longer operating time [MD (95%CI) = 31.62 (24.51, 38.72); p<0.001] and increased incisional SSI rates compared to their non-SFM counterparts [11.1% vs. 9.1%; OR (95%CI) = 1.23 (1.09, 1.40); p=0.0008]. A subgroup analysis of rectal cancer cases found significantly higher anastomotic leak rates with SFM [5.4% vs. 1.5%; OR (95%CI) = 2.37 (1.09, 5.16); p=0.03].
Conclusion: This systematic review found that SFM was not associated with significantly decreased anastomotic leak rates. SSI rates were significantly increased in patients undergoing SFM.
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Side-to-Side Anastomosis In Left Hemicolectomy, Why and When: A Single-Center Experience
Simona Macina, MD, Resident in General Surgery, Mikaela Imperatore, MD, Consultant, Cosimo Feleppa, MD, Consultant, Francesco Sucameli, MD, Resident in General Surgery, Giuseppina Talamo, MD, Resident in General Surgery, Emilio Falco, MD, Former Head of Department, Stefano Berti, MD, Head of Department, Department of General Surgery, Sant’Andrea Hospital ASL5, La Spezia, Italy
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BACKGROUND: Laparoscopic colectomy represents a safe, effective and well-established procedure for both benign and malignant colic disease. Transanal anastomosis (TA) with a circular stapler is the most commonly performed anastomotic technique in laparoscopic left hemicolectomy (LLH). We report our experience with side-to-side anastomosis (STSA) and side-to-end anastomosis (STEA) in selected patients with both emergency and elective LLH.
METHODS: A systematic review of the PubMed database was performed on recent studies that compared different anastomotic techniques after LLH. We collected internal data from June 2014 to July 2018 and compared our experience with the literature. The primary outcome was the anastomotic complication rate.
RESULTS: During the observation period, 158 patients underwent left hemicolectomy (LH). One-hundred-nineteen patients had malignant disease; 36 underwent surgery for complicated diverticular disease, one had a large strangulated incisional hernia, one had a sigmoid volvulus, and one had a sigmoid localization of endometriosis. Thirty open left hemicolectomies were performed. In 128 cases, a minimally invasive approach was used. Since conversion to open was necessary in 10 of these cases, 118 were totally LLH. STSA was performed in 64 cases; seven in an emergency setting and 57 in elective procedures. The overall anastomotic leak rate was 3.1% (2/64) and no anastomotic leak was reported in the emergency group (0/7). TA was performed in 15 cases, 93% in an elective setting (14/15), and the anastomotic leak rate was 13.3% (2/15). In 20 cases, we performed elective STEA and no anastomotic leak was recorded. In 19 cases, it was impossible to perform anastomosis and we decided to create a definitive colostomy.
CONCLUSION: Consistent with the literature data, our experience shows that, in selected cases, STSA and STEA are both safe and effective, with a lower anastomotic complication rate than TA.
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THD Doppler: A Reliable Surgical Procedure to Treat Hemorrhoids
Mahir Gachabayov, MD, PhD, Research Scholar, New York Medical College, Valhalla, NY, USA, George Angelos, MD, Assistant Professor of Surgery, Sanford University of South Dakota Medical School, Sioux Falls, SD, USA, Roberto Bergamaschi, MD, PhD, Professor and Chief, Section of Colorectal Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
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The search for alternatives to excisional surgery for internal hemorrhoids has been motivated by a desire to reduce postoperative pain and its associated disability as well as chronic sequelae. Among several non-excisional procedures, Doppler-guided transanal hemorrhoidal dearterialization (THD Doppler) has emerged as an alternative that offers minimal postoperative pain. However, there is some skepticism regarding the ligation of hemorrhoidal arteries, the usefulness of Doppler guidance, and the recurrence rates after THD Doppler. The aim of this narrative review is to compare THD to both non-excisional alternatives, such as rubber band ligation and stapled hemorrhoidopexy, and excisional alternatives, such as Ferguson hemorrhoidectomy. The authors seek to give readers concise insight into the evidence available in the English literature. This report does not offer a quantitative synthesis of the data, but rather highlights the role of THD Doppler in the treatment of internal hemorrhoids.
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Transperineal Excision of Rectal Gastrointestinal Stromal Tumor
Inna Tulina, MD, PhD, Associate Professor of Surgery, Yuriy Kitsenko, MD, PhD, Assistant Professor of Surgery, Alexandr Lukyanov, Medical Student, Petr Tsarkov, MD, PhD, Professor of Surgery, Sechenov First Moscow State Medical University, Moscow, Russia, Roberto Bergamaschi, MD, PhD, Professor of Surgery, Colorectal Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Gastrointestinal stromal tumors (GIST) of the rectum occur in approximately 4% of patients with rectal malignancies. Herein, we demonstrate a transperineal approach as a safe surgical technique for GISTs located anterior to the rectum. The proposed technique allows safe and effective excision of a tumor without disturbing the rectal anterior wall. Unlike previous techniques, this method stresses the importance of accurate preoperative assessment and use of the surgeon’s finger in the rectum to facilitate rectal wall preservation.
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Evaluation of the Educational Environment of a Cadaver Course in Robotic Colorectal Surgery: A Cross-sectional Study
Mahir Gachabayov, MD, PhD, Research Fellow, Karen You, BS, Research Assistant, George Angelos, MD, Attending Surgeon, Ryan Bendl, MD, Attending Surgeon, Cristan Anderson, MD, Attending Surgeon, Rahila Essani, MD, Attending Surgeon, Julia Zakhaleva, MD, Attending Surgeon, Salim Amrani, MD, Attending Surgeon, Moshe Barnajian, MD, Attending Surgeon, Joshua Karas, MD, Attending Surgeon, Roberto Bergamaschi, MD, Professor and Chief, Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY
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Background: The educational environment is a crucial metric of medical education that affects the course participants’ motivation, achievement, happiness and success. The aim of this study was to evaluate the educational environment of a cadaver course in robotic colorectal surgery by comparing the perceptions of the participating residents to those of the participating surgeons.
Methods: This was a cross-sectional study carried out in 2017. Participants from the U.S. and Europe attended a course using eight fresh frozen cadaver torsos with no prior abdominal surgery. After course completion, participants anonymously completed 50-item Dundee Ready Educational Environment Measure (DREEM) questionnaires to evaluate five components of the educational environment: perception of learning, perception of teachers, academic self-perception, perception of atmosphere, and social self-perception. Internal consistency of the questionnaire was assessed using Cronbach’s alpha coefficient. Mean scores were compared using an independent samples t-test.
Results: Twenty of 24 participants completed the DREEM questionnaire, consisting of 9 residents and 11 surgeons (12 from the U.S., 8 from Europe). The internal consistency of the questionnaire was excellent (alpha=0.97). The mean total score was excellent for both residents and surgeons, and the difference between the groups was not significant (154.1±25.8 vs. 168.1±18.9, p=0.197). Perception of learning was significantly better among surgeons (“teaching highly thought of”) than among residents (“a more positive perception”) (40.5±3.6 vs. 35.7±5.6, p=0.04).
Conclusions: This study suggests that the residents’ perception of learning may have been negatively influenced by the participation of surgeons in the same cadaver station.
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Effect of Neoadjuvant Chemotherapy in Patients with Colorectal Cancer Liver Metastases
Kenta Sui, MD, Chief Physician, Takehiro Okabayashi, MD, PhD, Division Manager, Jun Iwata, MD, PhD, Head of Medical Pathology, Sojiro Morita, MD, PhD, Vice President, Takatsugu Matsumoto, MD, PhD, Chief Physician, Ryo Inada, MD, PhD, Chief Physician, Tatsuo Iiyama, MD, PhD, Division Manager, Yasuhiro Shimada, MD, PhD, Director, Michiya Kobayashi, MD, PhD, Chair Professor, Kochi Medical School, Kochi, Japan
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Background: This study was performed to evaluate the relationships between potential prognostic factors and post-surgery survival in patients with colorectal cancer liver metastasis (CRLM). In particular, this study investigated the value of neoadjuvant chemotherapy as an independent predictor of cancer-specific survival.
Methods: The study participants included 147 patients who underwent resection for CRLM. Demographics, treatments, and relationships between potential prognostic factors and the survival rate were analyzed using a prospective database.
Results: The overall 1-, 3- and 5-year cancer-specific survival rates for post-surgery CRLM patients were 94.3%, 71.2%, and 53.5%, respectively. Multivariate analysis revealed that a positive surgical margin and extrahepatic metastasis were independent negative prognostic factors. The administration of neoadjuvant chemotherapy prior to liver surgery did not significantly improve post-surgery outcomes of patients with CRLM. In a subgroup analysis, the time to recurrence in the remnant liver after hepatectomy for CRLM was significantly less in the neoadjuvant group than in the upfront surgery group.
Conclusions: Neoadjuvant chemotherapy was not predictive of cancer-specific survival. The achievement of macroscopically and microscopically negative resection remains the main aim of surgery.
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Primary Anastomosis for Perforated Diverticulitis with Peritonitis: Post-hoc Pooled Analysis of Prospective Randomized Trials
Mahir Gachabayov, MD, PhD, Research Fellow, Roberto Bergamaschi, MD, PhD, Chief, Professor of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA, Christian E Oberkofler, MD, Attending Surgeon, Hospital University Zurich, Zurich, Switzerland, Gian Andrea Binda, MD, Professor of Surgery, Galliera Hospital, Genoa, Italy, Jean-Marc Regimbeau, MD, PhD, Professor of Surgery, Jean-Jacques Tuech, MD, PhD, Professor of Surgery, Rouen University Hospital, Rouen, France, Dieter Hahnloser, MD, PhD, Professor of Surgery, University Hospital Lausanne, Lausanne, Switzerland
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Background: The impact of specific interventions at resection with primary anastomosis (PRA) for perforated diverticulitis with peritonitis is controversial. The aim of this pooled analysis was to determine whether any specific interventions performed at resection with primary anastomosis in patients with perforated diverticulitis with peritonitis influenced the outcomes.
Methods: A post-hoc analysis of pooled data for 254 patients enrolled in three randomized trials that compared PRA to nonrestorative resection (NRR) (NCT01239927; NCT01233713; NCT00692393) was carried out. The primary endpoint was the postoperative complication rate. All patients were adults with perforated diverticulitis with purulent or fecal peritonitis. Specific interventions performed within PRA included intraoperative on-table colonic lavage, anastomosing technique (hand-sewn or stapled), diverting ostomy, and different types of ostomy (colostomy or ileostomy).
Results: A total of 116 PRA patients and 138 NRR patients were included in the randomized trials, but only patients undergoing PRA (n=116) were included in the pooled analysis. A negative correlation was found between colonic lavage and postoperative complication rates (rs=-0.482; p=0.011). Positive correlations were found between postoperative complication rates and both stapled anastomoses (rs=0.224; p=0.019) and the creation of an ostomy (rs=0.327; p<0.001). The type of ostomy was not correlated with postoperative complication rates.
Conclusion: Intraoperative colonic lavage and hand-sewn PRA were associated with decreased complication rates. The data seem to suggest that the addition of an ostomy may be correlated with increased rates of complications specifically related to ostomy creation.
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