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Kotze PG, Avellaneda N, Moretti RDAM, Carvello M, Tomada EP, Campos FG, Spinelli A. Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques. Dis Colon Rectum 2024; 67:S26-S35. [PMID: 38710588 DOI: 10.1097/dcr.0000000000003292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION IPAA technique. MAIN OUTCOME MEASURES Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
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Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Nicolas Avellaneda
- General and Colorectal Surgery Department, CEMIC University Hospital, Buenos Aires, Argentina
| | | | - Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisa Paoluzzi Tomada
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Mata R, Sahnan K, Pellino G, Spinelli A, Espín-Basany E. Robotic Total Mesorectal Excision With Transanal Transection and Single-Stapled Anastomosis: A Step-By-Step Video Demonstration. Dis Colon Rectum 2024; 67:e289-e290. [PMID: 38294827 DOI: 10.1097/dcr.0000000000003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Rodrigo Mata
- Colorectal Surgery Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Kapil Sahnan
- Department of Colorectal Surgery, St. Mark's Hospital and Academic Institute, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, St. Mary's Hospital, London, United Kingdom
| | - Gianluca Pellino
- Colorectal Surgery Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital -, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Eloy Espín-Basany
- Colorectal Surgery Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain
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3
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Potolicchio A, Jehaes C, Merlot B, Assenat V, Dennis T, Roman H, Francois MO, Denost Q. Treatment techniques for rectovaginal fistulas after low rectal resection for deep endometriosis. Tech Coloproctol 2024; 28:51. [PMID: 38684547 DOI: 10.1007/s10151-024-02923-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/16/2024] [Indexed: 05/02/2024]
Abstract
Endometriosis is a benign gynecologic affection that may lead to major surgeries, such as colorectal resections. Rectovaginal fistulas (RVF) are among the possible complications. When they occur, it is necessary to adapt the repair surgery as best as possible to limit their functional consequences. This video shows three different techniques for correcting RVF after rectal resection for endometriosis, with a combination of perineal surgery and laparoscopy: a mucosal flap, a transanal transection and single stapled anastomosis (TTSS) and a pull through. Supplementary file1 (MP4 469658 KB).
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Affiliation(s)
- A Potolicchio
- Clinique Tivoli-Ducos, Bordeaux Colorectal Institute, Bordeaux, France
| | - C Jehaes
- Clinique Tivoli-Ducos, Bordeaux Colorectal Institute, Bordeaux, France.
| | - B Merlot
- Clinique Tivoli-Ducos, Franco-European Multidisciplinary Endometriosis Institute, Bordeaux, France
| | - V Assenat
- Clinique Tivoli-Ducos, Bordeaux Colorectal Institute, Bordeaux, France
| | - T Dennis
- Clinique Tivoli-Ducos, Franco-European Multidisciplinary Endometriosis Institute, Bordeaux, France
| | - H Roman
- Clinique Tivoli-Ducos, Franco-European Multidisciplinary Endometriosis Institute, Bordeaux, France
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - M-O Francois
- Clinique Tivoli-Ducos, Bordeaux Colorectal Institute, Bordeaux, France
| | - Q Denost
- Clinique Tivoli-Ducos, Bordeaux Colorectal Institute, Bordeaux, France
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Francesco C, Serafino V. Colorectal eversion technique combined with modified single-stapled double-purse-string low colorectal anastomosis. Colorectal Dis 2024; 26:772-775. [PMID: 38372032 DOI: 10.1111/codi.16907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 02/20/2024]
Abstract
AIM Total mesorectal excision with adequate free margins is the gold standard for rectal surgery. Applying a linear stapler in a narrow pelvis can be challenging and the proper distal margin difficult to assess. In selected cases the colorectal eversion technique combined with single-stapled double-purse-string anastomosis (SSDP) can be a practical solution. METHOD Eleven patients, six men and five women, mean body mass index 27 ± 1.3 kg/m2, underwent total mesorectal excision with the colorectal eversion technique combined with modified SSDP between September 2022 and January 2023. RESULTS The mean operative time was 190 min. The mean hospital stay was 4 days. There were no postoperative complications. The final histology showed complete mesorectal resection, circumferential resection margin negative, free distal resection margin, anastomotic doughnuts negative. At 7 ± 3 months follow-up there was no evidence of local recurrence or distant metastasis. CONCLUSION The colorectal eversion technique combined with modified SSDP is a reproducible and safe technique in selected patients. Prospective randomized trials with large patient series are needed to confirm our preliminary results.
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Affiliation(s)
- Crafa Francesco
- Oncological, General and Robotic Surgery Unit, S. Giuseppe Moscati Hospital, Avellino, Italy
| | - Vanella Serafino
- Oncological, General and Robotic Surgery Unit, S. Giuseppe Moscati Hospital, Avellino, Italy
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Maestro de Castro JL, Choolani Bhojwani E, Labarga Rodríguez F, Bueno Cañones AD, Veleda Belanche S, Simó Fernández V. Robotic minimally invasive abdominal surgery and transanal transection and single-stapled anastomosis for low rectal cancer-A video vignette. Colorectal Dis 2024; 26:826-827. [PMID: 38424701 DOI: 10.1111/codi.16921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/30/2023] [Indexed: 03/02/2024]
Affiliation(s)
| | - Ekta Choolani Bhojwani
- Section of Colorectal Surgery, Department of Surgery, University Hospital Río Hortega, Valladolid, Spain
| | - Fernando Labarga Rodríguez
- Section of Colorectal Surgery, Department of Surgery, University Hospital Río Hortega, Valladolid, Spain
| | | | - Sandra Veleda Belanche
- Section of Colorectal Surgery, Department of Surgery, University Hospital Río Hortega, Valladolid, Spain
| | - Vicente Simó Fernández
- Section of Colorectal Surgery, Department of Surgery, University Hospital Río Hortega, Valladolid, Spain
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D'Ancona G, Merlot B, Denost Q, Angioni S, Dennis T, Roman H. Combined Robotic Transanal Transection Single-Stapled Technique in Ultralow Rectal Endometriosis Involvement Associated With Parametrial and Vaginal Infiltration. J Minim Invasive Gynecol 2024; 31:267-268. [PMID: 38160748 DOI: 10.1016/j.jmig.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/27/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To describe a combined robotic and transanal technique used to treat ultralow rectal endometriosis in a 36-year-old patient with multiple pelvic compartments, which was responsible for infertility, dyspareunia, left sciatic pain, and severe dyschezia. DESIGN Surgical video article. SETTING The achievement of a perfect bowel anastomosis in patients with low rectal endometriosis could be challenging owing to technical and anatomic limitations [1]. By allowing a right angle rectotomy with a single-stapled anastomosis, the transanal transection single-stapled technique overcomes these technical difficulties ensuring a good-quality anastomosis with an easier correction of postoperative anastomotic leakage when it occurs [2,3]. INTERVENTIONS The surgery starts by splitting the nodule in 3 components according to different anatomic structures involved (parametrium, vagina, and rectum). Parametrial and vaginal fragments are excised as previously described (Supplemental Videos 1) [4]. The rectal involvement is approached following several steps: isolation and cut of inferior mesenteric vessels (inferior mesenteric artery and inferior mesenteric vein) and left colic artery to obtain a proper colon mobilization; transanal rectotomy immediately below the lower limit of the nodule; extraction of the specimen through the anus (Supplemental Videos 2); proximal bowel segment transection 1 cm above the upper limit of the nodule; introduction of circular stapler anvil into the sigmoid colon; placement of 2 purse string to secure the anvil and at distal rectal cuff, respectively; connection of the anvil to the shoulder of circular stapler; stapler closing and firing with coloanal anastomosis formation; stapled line reinforcement by stitching; and integrity anastomosis test (Supplemental Videos 3). No preventive diverting stoma was performed in accordance with our policy [5]. CONCLUSIONS Although no data are yet available in patients with endometriosis, the use of transanal transection single-stapled technique may be an interesting approach in patients with very low rectal endometriosis involvement.
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Affiliation(s)
- Gianmarco D'Ancona
- Franco-European Multidisciplinary Endometriosis Institut (IFEMEndo) (Drs. D'Ancona, Merlot, Dennis, and Roman), Clinique Tivoli-Ducos, Bordeaux, France; Division of Obstetrics and Gynecology, Department of surgical sciences, University of Cagliari, Cagliari, Italy (Drs. D'Ancona and Angioni).
| | - Benjamin Merlot
- Franco-European Multidisciplinary Endometriosis Institut (IFEMEndo) (Drs. D'Ancona, Merlot, Dennis, and Roman), Clinique Tivoli-Ducos, Bordeaux, France; Franco-European Multidisciplinary Endometriosis Institut-Middle East Clinic, Burjeel Medical City, Abu Dhabi, UAE (Drs. Merlot and Roman)
| | - Quentin Denost
- Bordeaux Colorectal Institute (Dr. Denost), Clinique Tivoli-Ducos, Bordeaux, France
| | - Stefano Angioni
- Division of Obstetrics and Gynecology, Department of surgical sciences, University of Cagliari, Cagliari, Italy (Drs. D'Ancona and Angioni)
| | - Thomas Dennis
- Franco-European Multidisciplinary Endometriosis Institut (IFEMEndo) (Drs. D'Ancona, Merlot, Dennis, and Roman), Clinique Tivoli-Ducos, Bordeaux, France
| | - Horace Roman
- Franco-European Multidisciplinary Endometriosis Institut (IFEMEndo) (Drs. D'Ancona, Merlot, Dennis, and Roman), Clinique Tivoli-Ducos, Bordeaux, France; Franco-European Multidisciplinary Endometriosis Institut-Middle East Clinic, Burjeel Medical City, Abu Dhabi, UAE (Drs. Merlot and Roman)
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Maspero M, Liska D, Kessler H, Lipman J, Steele SR, Hull T, Qazi T, Rieder F, Cohen B, Holubar SD. Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease. Tech Coloproctol 2024; 28:38. [PMID: 38451358 DOI: 10.1007/s10151-023-02909-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/24/2023] [Indexed: 03/08/2024]
Abstract
ABTRACT BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications. METHODS We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm. RESULTS Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). CONCLUSION LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - David Liska
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Taha Qazi
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA.
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Mariusdottir E, Jörgren F, Saeed M, Wikström J, Lydrup ML, Buchwald P. Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study. Langenbecks Arch Surg 2024; 409:55. [PMID: 38321307 PMCID: PMC10847187 DOI: 10.1007/s00423-024-03237-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure. METHODS Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis. RESULTS Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure. CONCLUSIONS The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.
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Affiliation(s)
- Elin Mariusdottir
- Department of Surgery, Helsingborg Hospital, Charlotte Yhlens gata 10, 25223, Helsingborg, Sweden.
- Lund University, Lund, Sweden.
| | - Fredrik Jörgren
- Department of Surgery, Helsingborg Hospital, Charlotte Yhlens gata 10, 25223, Helsingborg, Sweden
- Lund University, Lund, Sweden
| | - Maria Saeed
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jens Wikström
- Lund University, Lund, Sweden
- Department of Surgery, Kristianstad Hospital, Kristianstad, Sweden
| | - Marie-Louise Lydrup
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Pamela Buchwald
- Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Cavallaro P, Lee GC, Kanters A, Valente M, Holubar SD, Champagne B, Rosen D, Gorgun E, Steele S. Fact or fiction? Does the position of the end-to-end (EEA) stapler spike matter for colorectal anastomoses using a double-stapled technique? Colorectal Dis 2024; 26:137-144. [PMID: 38083875 DOI: 10.1111/codi.16833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 01/28/2024]
Abstract
AIM Surgeons often have strong opinions about how to perform colorectal anastomoses with little data to support variations in technique. The aim of this study was to determine if location of the end-to-end (EEA) stapler spike relative to the rectal transection line is associated with anastomotic integrity. METHOD This study was a retrospective analysis of a quality collaborative database at a quaternary centre and regional hospitals. Patients with any left-sided colon resection with double-stapled anastomosis were included (December 2019 to August 2022). Our primary endpoint was a composite outcome including positive air insufflation test, incomplete anastomotic donut, or thin/eccentric donut. Our secondary endpoint was clinical leak. RESULTS Overall, 633 patients were included and stratified by location of the stapler spike relative to the rectal transection line. Of note, 86 patients had an end-colon to anterior rectum ("reverse Baker") anastomosis with no crossing staple lines. The rates of the composite endpoint based on position of the stapler spike were 12.4% (anterior), 8.1% (through), 12.8% (posterior), 5.1% (corner), and 2.3% for the "reverse Baker" (p = 0.03). The overall rate of clinical leak was 3.8% and there were no differences between methods. In a multivariate analysis, the "reverse Baker" anastomosis was associated with decreased odds of poor anastomotic integrity when compared to anastomoses with crossing staple lines (OR 0.20, 95% CI: 0.05-0.87, p = 0.03). CONCLUSIONS For anastomoses with crossing staple lines, the position of the stapler spike relative to the rectal staple line is not associated with differences in anastomotic integrity. In contrast, anastomoses with no crossing staple lines resulted in significantly lower rates of poor anastomotic integrity, but no difference in clinical leaks.
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Affiliation(s)
- Paul Cavallaro
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Grace C Lee
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arielle Kanters
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Valente
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bradley Champagne
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Rosen
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Gallo G, Goglia M. Grand challenges in colorectal and proctological surgery. Front Surg 2023; 10:1331877. [PMID: 38186385 PMCID: PMC10766734 DOI: 10.3389/fsurg.2023.1331877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Affiliation(s)
- Gaetano Gallo
- Department of Surgery, Sapienza University of Rome, Rome, Italy
- Colorectal and Proctological Surgery Section, Frontiers in Surgery
| | - Marta Goglia
- Colorectal and Proctological Surgery Section, Frontiers in Surgery
- Departmentof Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Harji D, Fernandez B, Boissieras L, Celerier B, Rullier E, Denost Q. IDEAL Stage 2a/b prospective cohort study of transanal transection and single-stapled anastomosis for rectal cancer. Colorectal Dis 2023; 25:2346-2353. [PMID: 37919463 DOI: 10.1111/codi.16789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 11/04/2023]
Abstract
AIM There are several anastomotic techniques available to facilitate restorative rectal cancer surgery after total mesorectal excision (TME), including double-stapled anastomosis (DST) and handsewn coloanal anastomosis (CAA). However, to date no one technique is superior with regard to anastomotic leakage (AL) or functional outcomes. Transanal transection single-stapled anastomosis (TTSS) aims to overcome some of the technical challenges and offer comparable clinical and functional outcomes to traditional anastomotic techniques. The aim of this study was to explore the role of TTSS in modern rectal cancer surgery and to provide comparative clinical and functional outcome data with DST and CAA. METHOD A prospective cohort study was undertaken to assess the safety and clinical and patient-reported outcomes associated with the TTSS procedure. All patients undergoing sphincter-preserving surgery for rectal cancer with an anastomosis performed within 6 cm of the anal verge between January 2016 and April 2021 were prospectively enrolled into this study. Clinical and patient-reported outcome data, including low anterior resection syndrome (LARS) assessment, were collected. The primary endpoint was anastomotic leakage within 30 days. RESULTS A total of 275 patients participated in this study, with 70 (25%) patients undergoing a TTSS, 110 (40%) undergoing a DST and 95 (35%) undergoing a CAA. Patients undergoing a CAA had more distal tumours than those having a TTSS or DST, with a median tumour height of 5, 7 and 9 cm (p < 0.001), respectively. We observed a statistically significant reduction in AL in the TTSS group compared with the DST group, with rates of 8.6% versus 20.9% (p = 0.028). There was no difference in LARS scores between patients undergoing TTSS and DST (p = 0.228), while patients with a CAA had worse LARS scores than TTSS patients (p = 0.002). CONCLUSION TTSS is a technically safe and feasible anastomotic technique in rectal cancer surgery as an alternative to DST and CAA. Its advantages over DST are a reduced AL rate and, over CAA, improved function. It should therefore be considered as an alternative technique to improve clinical and patient-reported outcomes in restorative rectal cancer surgery.
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Affiliation(s)
- Deena Harji
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Benjamin Fernandez
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Lara Boissieras
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Bertrand Celerier
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Eric Rullier
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
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Francesco C, Serafino V, Mario B, Antonio L. Colorectal eversion technique combined with modified DST (CET-M-DST) for low colorectal anastomosis after laparoscopic TME for colorectal cancer - Video correspondence. Colorectal Dis 2023; 25:2473-2474. [PMID: 37932880 DOI: 10.1111/codi.16802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/11/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Crafa Francesco
- Oncological, General and Robotic Surgery Unit, S.Giuseppe Moscati Hospital, Avellino, Italy
| | - Vanella Serafino
- Oncological, General and Robotic Surgery Unit, S.Giuseppe Moscati Hospital, Avellino, Italy
| | - Baiamonte Mario
- Oncological, General and Robotic Surgery Unit, S.Giuseppe Moscati Hospital, Avellino, Italy
| | - Longo Antonio
- European Center of Coloproctology and Pelvic Diseases, Multimedica Hospital, Milan, Italy
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14
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Fu Z, Li S, Zang L, Dong F, Cai Z, Ma J. Predicting multiple linear stapler firings in double stapling technique with an MRI-based deep-learning model. Sci Rep 2023; 13:18906. [PMID: 37919401 PMCID: PMC10622418 DOI: 10.1038/s41598-023-46225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 10/30/2023] [Indexed: 11/04/2023] Open
Abstract
Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid-low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15-5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level > 5 ng/mL [OR = 2.20, 95% CI = 1.20-4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid-low rectal cancer patients.
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Affiliation(s)
- Zhanwei Fu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Shuchun Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Lu Zang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Feng Dong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China.
| | - Junjun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China.
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15
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Spinelli A, Foppa C, Maroli A, Sacchi M, Armuzzi A, Danese S, Bemelman W, Carvello M. Transanal transection and single-stapling techniques are associated with shorter rectal cuff and lower urgency rate after pouch surgery compared with the double-stapled approach. Surgery 2023; 174:808-812. [PMID: 37517895 DOI: 10.1016/j.surg.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis is most commonly performed by double-stapling technique after rectal transection with a linear stapler. Double-stapling is increasingly criticized for the uneven longer cuffs and potential weak points. A transanal rectal transection and single-stapled anastomosis may potentially overcome the limitations of double-stapling. A single-stapled anastomosis may be accomplished through a transanal rectal transection followed by bottom-up dissection (transanal-ileal pouch-anal anastomosis) or through an abdominal, rectal dissection and subsequent transanal transection and single-stapled anastomosis. The purpose of this study is to compare short-term and functional outcomes of double-stapling versus single-stapled techniques for ileal pouch-anal anastomosis. METHODS This is a single-institution, ambidirectional study. Patients with ulcerative colitis undergoing ileal pouch-anal anastomosis between 2014 and 2021 were included in the study and allocated into 2 groups: group 1, including double stapled ileal pouch anal anastomosis, and group 2, including single-stapled-ileal pouch-anal anastomosis. The primary endpoint was the difference in functional parameters. RESULTS A total of 130 patients were included, 46 undergoing double-stapling-ileal pouch-anal anastomosis and 84 receiving single-stapled ileal pouch-anal anastomosis. Rectal-cuff length (defined as the distance between the dentate line and ileal pouch-anal anastomosis) was shorter after single-stapled compared with double-stapling ileal pouch-anal anastomosis (1.98 ± 0.21 vs 2.20 ± 0.53 cm, P = .01). Anastomotic leak rate was comparable between group 1 and group 2 (6% vs 5%, P = .69). Functional parameters were comparable except for urgency, which was lower for single-stapled compared with double-stapling ileal pouch-anal anastomosis (8%, vs 30%, P = .002). CONCLUSION Single-stapled ileal pouch-anal anastomosis was associated with a shorter rectal cuff and lower urgency than double-stapling ileal pouch-anal anastomosis. In our opinion, these results warrant a prospective multicentric trial to scrutinize and confirm these benefits on a larger scale.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy.
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Matteo Sacchi
- Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), San Raffaele Hospital, Milan, Italy
| | - Willem Bemelman
- Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), San Raffaele Hospital, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
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16
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Foppa C, Carvello M, Maroli A, Sacchi M, Gramellini M, Montorsi M, Spinelli A. Single-stapled anastomosis is associated with a lower anastomotic leak rate than double-stapled technique after minimally invasive total mesorectal excision for MRI-defined low rectal cancer. Surgery 2023; 173:1367-1373. [PMID: 36967334 DOI: 10.1016/j.surg.2023.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/13/2023] [Accepted: 02/11/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND After total mesorectal excision, distal rectal transection and anastomosis are critical for short-term, oncological, and functional outcomes, including anastomotic leak. A double-pursestring, single-stapled anastomosis avoids cross-stapling, overcoming the potential drawbacks of transabdominal rectal transection and double-stapled anastomosis. This study aims to compare the anastomotic leak rate in double-stapled and single-stapled anastomoses after minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer. METHODS Adult patients (>18 years old) undergoing minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer with a stapled low anastomosis (below 5 centimeters from the anal verge) between January 2010 and January 2022 at a single institution were allocated to 2 groups according to the anastomosis: double-stapled (abdominal stapled transection and double-stapled anastomosis) or single-stapled (transanal rectal transection and double-pursestring single-stapled anastomosis). The exclusion criteria were nonrestorative procedures or any type of manual anastomosis. The primary endpoint was the rate of 90-day clinical and radiologic anastomotic leak. RESULTS In total, 185 single-stapled and 458 double-stapled were included. Clinical and tumor characteristics were comparable between the groups. The 90-day anastomotic leak rate was significantly lower in the single-stapled group (6.48% vs 15.28%; P = .002), with similar rates of grade and timing. Thirty- and 90-day complication rates were higher in the double-stapled group (P = .0001; P = .02), with comparable Clavien-Dindo grades. At multivariable analysis, double-stapled anastomosis (P = .01), active smoking (P = .03), and the presence of comorbidities (P = .01) resulted as independent risk factors for an anastomotic leak. CONCLUSION Transanal transection and double-pursestring, single-stapled anastomosis were associated with a lower anastomotic leak rate after minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer.
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Affiliation(s)
- Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Annalisa Maroli
- IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Matteo Sacchi
- IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Marco Gramellini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy.
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Deputy M, Pitman F, Sahnan K, Miskovic D, Faiz O. An early experience in robotic ileoanal pouch surgery with robotic intracorporeal single-stapled anastomosis (RiSSA) at a tertiary referral centre. Colorectal Dis 2023. [PMID: 36806873 DOI: 10.1111/codi.16528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023]
Abstract
AIM A robotic approach to ileal pouch-anal anastomosis (IPAA) surgery offers advantages over other approaches in terms of precision, improved access to the pelvis and less muscular fatigue for the surgeon. The integrity of the anastomosis is also fundamental to successful IPAA surgery. The robotic platform can permit intracorporeal suturing deep within the pelvis to create a single-stapled, double purse-string anastomosis, which may reduce the risk of anastomotic complications. This study describes the safety and early outcomes of robotic intracorporeal single-stapled anastomosis (RiSSA) amongst patients operated consecutively at a tertiary centre immediately before and following the pandemic. METHOD A retrospective study of prospectively collected data analysing the outcome of patients undergoing robotic IPAA between 2019 and 2022 was conducted. All procedures were performed with the da Vinci Xi Surgical System (with a hand-assisted suprapubic incision to fashion the pouch). All pouch-anal anastomoses were performed using a double purse-string, single-stapled (RiSSA) method. Demographic, clinical and outcome data were collected. RESULTS Twenty consecutive patients (nine with ulcerative colitis and 11 with familial adenomatous polyposis) were included with a median age of 25 years (range 16-52); 18 had American Society of Anesthesiologists classification II, and mean body mass index was 24 kg/m2 (range 18.1-34.3). Nine patients (eight ulcerative colitis and one familial adenomatous polyposis) had undergone prior subtotal colectomy and therefore underwent restorative proctectomy with IPAA. Eleven patients underwent restorative proctocolectomy. All procedures were completed robotically. The median length of stay was 9 days (5-49). There were no unplanned admissions to intensive care and no deaths. Three patients were readmitted following hospital discharge for (i) an ileus managed conservatively, (ii) small bowel obstruction managed conservatively and (iii) small bowel obstruction due to constriction at the stoma site necessitating surgery. There were two additional reoperations both for drain complications, one for drain removal and one for drain erosion. On mobilization of the pouch in the latter case, an anastomotic defect was observed. In total, 19/20 patients underwent RiSSA without postoperative anastomotic problems. DISCUSSION RiSSA offers a safe and feasible alternative technique to other minimally invasive approaches with low rates of anastomosis-related complications.
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Affiliation(s)
- Mohammed Deputy
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Francesca Pitman
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Leicester University Medical School, George Davies Centre, Leicester, UK
| | - Kapil Sahnan
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Danilo Miskovic
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Omar Faiz
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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18
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Cai ZH, Zhang Q, Fu ZW, Fingerhut A, Tan JW, Zang L, Dong F, Li SC, Wang SL, Ma JJ. Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis. World J Gastroenterol 2023; 29:536-548. [PMID: 36688017 PMCID: PMC9850934 DOI: 10.3748/wjg.v29.i3.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/29/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Multiple linear stapler firings during double stapling technique (DST) after laparoscopic low anterior resection (LAR) are associated with an increased risk of anastomotic leakage (AL). However, it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis. AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging (MRI). METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis, which were randomly divided into a training set (n = 260) and testing set (n = 68). Binary logistic regression was adopted to create a clinical model using six factors. The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed. Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks. Sensitivity, specificity, accuracy, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) was calculated for each model. RESULTS The prevalence of ≥ 3 linear stapler cartridges was 17.7% (58/328). The prevalence of AL was statistically significantly higher in patients with ≥ 3 cartridges compared to those with ≤ 2 cartridges (25.0% vs 11.8%, P = 0.018). Preoperative carcinoembryonic antigen level > 5 ng/mL (OR = 2.11, 95%CI 1.08-4.12, P = 0.028) and tumor size ≥ 5 cm (OR = 3.57, 95%CI 1.61-7.89, P = 0.002) were recognized as independent risk factors for use of ≥ 3 linear stapler cartridges. Diagnostic performance was better with the integrated model (accuracy = 94.1%, PPV = 87.5%, and AUC = 0.88) compared with the clinical model (accuracy = 86.7%, PPV = 38.9%, and AUC = 0.72) and the image model (accuracy = 91.2%, PPV = 83.3%, and AUC = 0.81). CONCLUSION MRI-based deep learning model can predict the use of ≥ 3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery. This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for ≥ 3 linear stapler cartridges.
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Affiliation(s)
- Zheng-Hao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai 200025, China
| | - Qun Zhang
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai 201100, China
| | - Zhan-Wei Fu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Abraham Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jing-Wen Tan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Lu Zang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Feng Dong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shu-Chun Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shi-Lin Wang
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai 201100, China
| | - Jun-Jun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Kitaguchi D, Wakabayashi M, Hasegawa H, Ando K, Ikeda K, Tsukada Y, Nishizawa Y, Ito M. Single-stapling technique versus hand-sewn anastomosis in inter-sphincteric resection with transanal total mesorectal excision (Super SST): protocol for a multicentre randomized clinical trial. BJS Open 2023; 7:6987137. [PMID: 36638066 PMCID: PMC9838806 DOI: 10.1093/bjsopen/zrac160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Currently, hand-sewn anastomosis is the standard procedure for inter-sphincteric resection (ISR); however, distal purse-string suturing during transanal total mesorectal excision (TaTME) has allowed a single-stapling technique (SST). Although it was originally intended for cases requiring anastomosis of 2 cm or more above the anorectal junction (ARJ), SST could be safely performed in ISR. The aim of this trial is to determine the superiority of SST over hand-sewn anastomosis in ISR with TaTME. METHODS The Super SST trial is a multicentre randomized clinical trial comparing stapled and hand-sewn anastomoses in ISR with TaTME. The trial will recruit patients scheduled for TaTME with anastomosis below the ARJ, who will be allocated 1:1 to receive either hand-sewn or stapled anastomosis. The primary endpoint is anastomosis-related complications within 30 postoperative days. Secondary endpoints include all early and late complications, operating time, reoperation, mortality rate, length of postoperative hospital stay, readmission, incidence of anal pain and rectal mucosal prolapse, length of temporary stoma retention, the proportion of patients with a temporary stoma at 1 year after surgery, and anorectal function at 1 year after surgery. CONCLUSION This trial will provide important clinical insights for new and promising anastomotic options for patients with very low rectal cancer. Registration number: UMIN000047818 (https://www.umin.ac.jp/ctr/index-j.htme).
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Affiliation(s)
- Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masashi Wakabayashi
- Biostatistics Division, Center for Research Administration and Support, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Koji Ando
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaaki Ito
- Correspondence to: Masaaki Ito, Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan (e-mail: )
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LABALDE MARTÍNEZ M, NEVADO GARCÍA C, GARCÍA BORDA FJ, VIVAS LOPEZ A, GARCÍA VILLAR O, RUBIO GONZALEZ E, PELÁEZ TORRES P, FERRERO HERRERO E. Long-term outcomes of transanal total mesorectal excision for rectal cancer: what could we do to improve them? Minerva Surg 2022; 77:564-572. [DOI: 10.23736/s2724-5691.22.09463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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Comparison of Anastomotic Stricture/Stenosis After Transanal Total Mesorectal Excision for Rectal Cancer with Laparoscopic Total Mesorectal Excision. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03565-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Functional outcomes of transanal versus transabdominal restorative proctectomy with ileal pouch-anal anastomosis in ulcerative colitis-a monocentric retrospective comparative study. Langenbecks Arch Surg 2022; 407:3607-3614. [PMID: 35945298 DOI: 10.1007/s00423-022-02640-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) ensures satisfactory gastro-intestinal function and quality of life (QoL) in patients with refractory ulcerative colitis (UC). The transanal approach to proctectomy and IPAA (Ta-IPAA) has been developed to address the technical shortfalls of the traditional transabdominal approach (Tabd-IPAA). Ta-IPAA has proven to be safe but there is lack of reported functional outcomes. Aim of this study is to compare functional outcomes and QoL after Ta- or Tabd-IPAA for UC. METHODS This is a retrospective study of consecutive UC patients who underwent IPAA between 2011 and 2017, operated according to a modified 2- or 3-stage approach. Close rectal dissection was performed in Ta-IPAA as opposed to total mesorectal excision in Tabd-IPAA. A propensity score weighting was performed. Functional outcomes were assessed using the pouch functional score (PFS) and the Öresland score (OS). The global quality of life scale (GQOL) was used for patients' perspective on QoL. Follow-up was scheduled at 1, 3, 6, and 12 months, postoperatively. RESULTS One hundred and eight patients were included: 38 patients had Ta-IPAA. At 12 months follow-up, mean OS and PFS were 4.6 (CI 3.2-6.0) vs 6.2 (CI 5.0-7.3), p = 0.025 and 6.1 (CI 3.5-8.8) vs 7.4 (CI 5.4-9.5), p = 0.32, for Ta and Tabd-IPAA, respectively. Mean GQOL for Ta-IPAA was 82.5 (CI 74.8-90.1) vs 75.5 (69.4-81.7) for Tabd-IPAA (p = 0.045). CONCLUSIONS At 12 months postoperatively, pouch function and QoL of Ta-IPAA are probably as good as those of Tabd-IPAA. Limitations include retrospectivity, differences in the surgical technique, and lack of validated scores for QoL.
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Gearing PF, Larach JT, Mohan H, Cohen L, Heriot AG, Warrier SK. Utilization of a transanal approach to facilitate beyond total mesorectal excision dissection including en bloc subcortical high sacrectomy for locally recurrent rectal cancer. ANZ J Surg 2022; 92:2368-2370. [PMID: 35080334 DOI: 10.1111/ans.17486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/02/2022] [Accepted: 01/08/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Peter F Gearing
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - José Tomás Larach
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Helen Mohan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Lauren Cohen
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
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