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Crippa J, Magistro C, Montroni I, Borroni G, Ziccarelli A, Spinelli A, Mari GM. Charting connections: A systematic review of colorectal surgery research networks. Eur J Surg Oncol 2024; 50:108322. [PMID: 38653161 DOI: 10.1016/j.ejso.2024.108322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
Research in surgery faces intrinsic difficulties such as the lack of reproducibility of surgical operations, self-referring surgeons, decentralized data. Establishing a community of qualified researchers across surgeons is crucial. Clinical networks have been proposed as solutions to many challenges in surgical research, yet their implementation remains uncommon, especially for surgical trialists. The extent of literature produced by networks remains unclear, but fostering such collaborations could enhance the overall quality of surgical research. We conducted review focusing on research networks in colorectal surgery to assess their workload and impact in the literature and identify factors contributing to their durability. Following PRISMA guidelines, we searched for articles published through research networks. Networks were categorized by subspecialty, and specific items were retrieved for further classification. A survey was administered to twenty experts in colorectal surgery or research networking. A total of 2490 manuscripts were screened, and 397 networks identified. Of these, 96 were colorectal networks contributing to 492 publications, with 28 networks having five or more publications. Seventeen networks were affiliated with International or National societies, and only 5 conducted both prospective trials and RCTs. Twenty networks reported national or population-based data, and 26 networks lasted for more than 5 years. Sixteen experts participated in the survey, with an 80 % compliance rate, and 12 of them have been involved in creating a surgical network. The large majority of experts advocate the establishment of guidelines for networks creation in the surgical community.
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Affiliation(s)
- Jacopo Crippa
- Department of General Surgery, ASST Melegnano e Martesana, Via Pandina 1, Vizzolo Predabissi, Milan, 20070, Italy; AIMS Academy Clinical Research Network, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Carmelo Magistro
- Department of General Surgery, ASST Melegnano e Martesana, Via Pandina 1, Vizzolo Predabissi, Milan, 20070, Italy; AIMS Academy Clinical Research Network, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Isacco Montroni
- Division of Colorectal Surgery, Ospedale Santa Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy
| | - Giacomo Borroni
- AIMS Academy Clinical Research Network, Piazza Ospedale Maggiore 3, 20162, Milan, Italy; Chirurgia Generale Varese 1, ASST Settelaghi, Viale Borri 57, 21100, Varese, Italy
| | - Antonio Ziccarelli
- AIMS Academy Clinical Research Network, Piazza Ospedale Maggiore 3, 20162, Milan, Italy; General Surgery Department, ASUFC, Via Pozzuolo n° 330, 33100, Udine, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Giulio Maria Mari
- AIMS Academy Clinical Research Network, Piazza Ospedale Maggiore 3, 20162, Milan, Italy; Department of Colorectal Surgery, ASST Brianza, 20832, Viale Mazzini 1, Desio, MB, 20832, Italy
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Crippa J, Santambrogio G, Spinelli A, Montroni I, Cirocchi R, Fingerhut A, Mari GM. 'Reply to: Exploring the potential appropriateness of high ligation for a specific demographic'. Eur J Surg Oncol 2023; 49:106998. [PMID: 37543002 DOI: 10.1016/j.ejso.2023.106998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Jacopo Crippa
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Antonino Spinelli
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Isacco Montroni
- Colorectal Surgery and General Surgery, Ospedale per gli Infermi, Faenza, Italy
| | - Roberto Cirocchi
- Department of General Surgery, University of Perugia, Terni, Italy
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Austria and Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, PR China
| | - Giulio M Mari
- Colorectal Surgery Unit, ASST Brianza, Desio Hospital, Desio, Italy
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Crippa J, Calini G, Santambrogio G, Sassun R, Siracusa C, Maggioni D, Mari G. ERAS Protocol Applied to Oncological Colorectal Mini-invasive Surgery Reduces the Surgical Stress Response and Improves Long-term Cancer-specific Survival. Surg Laparosc Endosc Percutan Tech 2023; 33:297-301. [PMID: 37184246 DOI: 10.1097/sle.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/20/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are known to reduce postoperative complications and improve short-term outcomes by minimizing the surgical stress response (SSR). Retrospective reviews of large cohorts suggest that they may also have an impact on long-term oncological outcomes. In 2016, Mari et al published a randomized trial on ERAS protocol and the impact on the SSR; they found that IL-6 was less expressed in patients who undergo laparoscopic colorectal surgery within an ERAS protocol compared with controls. The aim of the present study is to report the long-term oncological outcomes of patients enrolled 5 years after the conclusion of the study. METHODS Patients enrolled had received the indication for major colorectal surgery, aged between 18 and 80 years, with American Society of Anesthesiologists (ASA) grades I to III, autonomous for mobilization and walking, eligible for laparoscopic technique. In total, 140 patients were enrolled and randomized into 2 groups of 70 patients each. Among these patients, 52 in the ERAS group (EG) and 53 in the Standard group (SG) had colorectal cancer. For them, a 5-year oncological follow-up according to the NCCN 16 guidelines was planned. IL-6, C-reactive protein, prolactine, white blood cell count, albumin, and prealbumin were compared between oncological patients in the EG and in the SG. RESULTS EG showed lower IL-6 on postoperative day 1 (21.2±9.1 vs. 40.3 ±11.3; P <0.05) and on day 5 (14.9±6.2 vs. 38.7±8.9; P <0.05), lower C-reactive protein on day 1 (48.3±15.7 vs. 89.4±20.3; P <0.05) and on day 5 (38.3±11.4 vs. 74.3±19.7; P <0.05), and lower pre-albumine on day 5 (18.9±7.2 vs. 12.3±6.9; P <0.05) compared with SG. Median oncological follow-up was 57 months [46.5 to 60]. There was no statistically significant difference in overall survival (log rank=0.195) and disease-free survival (Log rank=0.089) between groups. Cancer-specific survival was significantly better (log rank=0.038) in the EG compared with patients in the SG. CONCLUSIONS ERAS protocol applied to colorectal laparoscopic surgery for cancer is able to minimize the SSR. As a possible result, cancer-specific survival seems to be improved in patients within enhanced protocols. However, even though there may be an association between an excess of SSR and worse oncological outcomes, the favorable effect of ERAS protocols toward better overall and disease-free survival is yet to be demonstrated.
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Affiliation(s)
- Jacopo Crippa
- IRCCS Humanitas Research Hospital, ASST Melegnano-Martesana, Rozzano, Milan
| | | | | | | | - Claudia Siracusa
- Laboratory of Clinical Chemistry, Hospital of Desio, ASST-Brianza, Desio, MB
| | - Dario Maggioni
- General Surgery Departement, ASST Brianza, Brianza, Italy
| | - Giulio Mari
- General Surgery Departement, ASST Brianza, Brianza, Italy
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Mari G, Santambrogio G, Crippa J, Cirocchi R, Origi M, Achilli P, Ferrari G, Megna S, Desio M, Cocozza E, Maggioni D, Montroni I, Spinelli A, Zuliani W, Costanzi A, Crestale S, Petri R, Bicelli N, Pedrazzani C, Boccolini A, Taffurelli G, Fingerhut A. 5 year oncological outcomes of the HIGHLOW randomized clinical trial. Eur J Surg Oncol 2023; 49:641-646. [PMID: 36335077 DOI: 10.1016/j.ejso.2022.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/18/2022] [Accepted: 10/22/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. RESULTS Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. CONCLUSION We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.
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Affiliation(s)
- Giulio Mari
- Colorectal Surgery Unit ASST Brianza, DesioHospital, Desio, Italy.
| | | | - Jacopo Crippa
- Division of Colon& Rectal Surgery, IRCCSHumanitasResearchHospital, Rozzano, Milan, Italy
| | - Roberto Cirocchi
- Department of General Surgery, University of Perugia, Terni, Italy
| | - Matteo Origi
- General Surgery Department, Oncological and Mininvasive General Surgery, NiguardaHospital, Milano, Italy
| | - Pietro Achilli
- General Surgery Department, Oncological and Mininvasive General Surgery, NiguardaHospital, Milano, Italy
| | - Giovanni Ferrari
- General Surgery Department, Oncological and Mininvasive General Surgery, NiguardaHospital, Milano, Italy
| | - Stefano Megna
- Varese General Surgery, Department of Surgery, ASST SetteLaghi, Italy
| | - Matteo Desio
- Varese General Surgery, Department of Surgery, ASST SetteLaghi, Italy
| | - Eugenio Cocozza
- Varese General Surgery, Department of Surgery, ASST SetteLaghi, Italy
| | - Dario Maggioni
- Colorectal Surgery Unit ASST Brianza, DesioHospital, Desio, Italy
| | - Isacco Montroni
- ColorectalSurgery and General Surgery, Ospedale per gli Infermi, Faenza, Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Walter Zuliani
- Humanitas Mater Domini ClinicalInstitute, General Surgery, Castellanza, Varese, Italy
| | - Andrea Costanzi
- General Surgery Unit, San Leopoldo Mandic Hospital, Merate, ASST Lecco, Italy
| | - Sara Crestale
- General Surgery Unit, San Leopoldo Mandic Hospital, Merate, ASST Lecco, Italy
| | - Roberto Petri
- General Surgery Unit, University Hospital, Udine, Italy
| | | | - Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Andrea Boccolini
- Department of General and Emergency Surgery AOSP of Terni, Italy
| | | | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, MedicalUniversity of Graz, Austria and Department of General Surgery, RuijinHospital, ShanghaiJiaoTongUniversitySchool of Medicine, Shanghai Minimally Invasive SurgeryCenter, Shanghai, 200025, PR China
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Baldari L, Boni L, Cassinotti E, Crippa J, Mari G. Right Hemicolectomy with Complete Mesocolic Excision Using the Versius Surgical System: A Step-by-Step Guide. Chirurgia (Bucur) 2023; 118:54-62. [PMID: 36913418 DOI: 10.21614/chirurgia.2828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/14/2023]
Abstract
The application of new robotic platforms in colorectal surgery has increased greatly in the last 10 years. New systems have been released and entered the surgical panorama, broadening the technological offer. Robotic surgery applied to colorectal oncological surgery has been widely described. Hybrid robotic surgery in right sided colonic cancer has been previously reported. According to the site and local extension of a right-sided colon cancer, a different lymphadenectomy could be required. For more distant and locally advanced tumors a complete mesocolic excision (CME) is indicated. CME for right colon cancer is a complex operation compared to standard right hemicolectomy. Therefore a hybrid robotic system may be effectively applied to CME during a minimally-invasive right hemicolectomy to improve the dissection accuracy. Here we report a step-by-step hybrid laparoscopic/robotic right hemicolectomy with CME performed with the Versius Surgical System, a tele-operated surgical robotic system intended for the use of robotic assisted surgery.
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Luberto A, Crippa J, Foppa C, Maroli A, Sacchi M, De Lucia F, Carvello M, Spinelli A. Routine placement of abdominal drainage in pouch surgery does not impact on surgical outcomes. Updates Surg 2022; 75:619-626. [PMID: 36479676 PMCID: PMC9734453 DOI: 10.1007/s13304-022-01411-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/22/2022] [Indexed: 12/12/2022]
Abstract
The evidence does not support the routine use of abdominal drainage (AD) in colorectal surgery. However, there is no data on the usefulness of AD, specifically, after ileal pouch-anal anastomosis (IPAA). The aim of this study is to assess post-operative outcomes of patients undergoing IPAA with or without AD at a high volume referral center. A retrospective analysis of prospectively collected data of consecutive patients undergoing IPAA with AD (AD group) or without AD (NAD group) was performed. Baseline characteristics, operative, and postoperative data were analyzed and compared between the two groups. A total of 97 patients were included in the analysis, 46 were in AD group and 51 in NAD group. AD group had a higher BMI (23.9 ± 3.9 kg/m2 vs 21.9 ± 3.0 kg/m2; p = 0.007) and more commonly underwent two-stage proctocolectomy with IPAA compared to the NAD group (50.0% vs 3.9%; p < 0.001). There was no difference in anastomotic leak rate (6.5% AD vs 5.9% NAD group; p = 1.000), major post-operative complication (8.6% vs 7.9%; p = 0.893); median length of stay [IQR] (5 [5-7] days vs 5 [4-7] days; p = 0.305) and readmission < 90 days (8.7% vs 3.9%; p = 0.418). The use of AD does not impact on surgical outcome after IPAA and question the actual benefit of its routine placement.
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Affiliation(s)
- Antonio Luberto
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Jacopo Crippa
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan Italy ,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Annalisa Maroli
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Matteo Sacchi
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Francesca De Lucia
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan Italy ,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan Italy ,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
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Di Fratta E, Mari G, Crippa J, Siracusa C, Costanzi A, Sassun R, Maggioni D, Fingerhut A. Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience. Updates Surg 2022; 74:1665-1673. [PMID: 35804223 DOI: 10.1007/s13304-022-01324-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O2 therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.
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Affiliation(s)
| | - Giulio Mari
- General Surgery Unit, Hospital of Desio, ASST Brianza, Desio, MB, Italy
| | - Jacopo Crippa
- IRCCS Humanitas Research Hospital, ASST Melegnano-Martesana, Rozzano, Milan, Italy
| | - Claudia Siracusa
- Laboratory of Clinical Chemistry, Hospital of Desio, ASST-Brianza, Desio, MB, Italy
| | - Andrea Costanzi
- General Surgery Unit, Merate Hospital, ASST Lecco, Merate, LC, Italy
| | - Richard Sassun
- General Surgery Unit, Hospital of Desio, ASST Brianza, Desio, MB, Italy.
| | - Dario Maggioni
- General Surgery Unit, Hospital of Desio, ASST Brianza, Desio, MB, Italy
| | - Abe Fingerhut
- AIMS Academy Clinical Research Network, ASST Grande Ospedale Metropolitano Niguarda, Milan, MI, Italy
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Crippa J, Altomare DF, Spinelli A. Cutting-Edge Research Trends in Colorectal Disease. J Clin Med 2022; 11:jcm11041036. [PMID: 35207309 PMCID: PMC8875354 DOI: 10.3390/jcm11041036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jacopo Crippa
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Donato F. Altomare
- Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Umberto I Square, 70121 Bari, Italy;
| | - Antonino Spinelli
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
- Correspondence: ; Tel.: +39-028-224-4513
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Pedrazzani C, Turri G, Park SY, Hida K, Fukui Y, Crippa J, Ferrari G, Origi M, Spolverato G, Zuin M, Bae SU, Baek SK, Costanzi A, Maggioni D, Son GM, Scala A, Rockall T, Larson DW, Guglielmi A, Choi GS. Laparoscopic versus open surgery for left flexure colon cancer: A propensity score matched analysis from an international cohort. Colorectal Dis 2022; 24:177-187. [PMID: 34706130 PMCID: PMC9299165 DOI: 10.1111/codi.15962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/20/2021] [Accepted: 10/22/2021] [Indexed: 12/20/2022]
Abstract
AIM Surgical treatment of splenic flexure cancer (SFC) still presents some debated issues, including the role of laparoscopic surgery. The literature is based on small single-centre series, while randomized controlled studies comparing open and laparoscopic treatment for colon cancer exclude SFC. This study aimed to determine the role of laparoscopic surgery in the treatment of SFC, comparing short- and long-term outcomes with open surgery. METHOD This was an international multicentre retrospective cohort study that analysed patients from 10 tertiary referral centres. From a cohort of 641 cases, 484 patients with Stage I-III SFC submitted to elective surgery with curative intent were selected. After 1:1 propensity score matching, 130 patients in the laparoscopic group (LapGroup) were compared with 130 patients in the open surgery group (OpenGroup). RESULTS After propensity score matching, the two groups were comparable for demographic and clinical parameters. OpenGroup presented a higher incidence of overall (P = 0.02) and surgery-related complications (P = 0.05) but a similar rate of severe complications (P = 0.75). Length of stay was notably shorter in the LapGroup (P = 0.001). Overall (P = 0.793) as well as cancer-specific survival (P = 0.63) did not differ between the two groups. CONCLUSIONS Elective laparoscopic surgery for Stage I-III SFC is feasible and associated with improved short-term postoperative outcomes compared to open surgery. Moreover, laparoscopic surgery appears to provide excellent long-term cancer outcomes.
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Affiliation(s)
- Corrado Pedrazzani
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynecology and PediatricsUniversity of VeronaVeronaItaly
| | - Giulia Turri
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynecology and PediatricsUniversity of VeronaVeronaItaly
| | - Soo Yeun Park
- Colorectal Cancer CentreKyungpook National University Medical CentreSchool of MedicineKyungpook National UniversityDaeguKorea
| | - Koya Hida
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Yudai Fukui
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Jacopo Crippa
- Division of Colon and Rectal SurgeryDepartment of SurgeryMayo ClinicRochesterMinnesotaUSA
| | - Giovanni Ferrari
- Department of General SurgeryNiguarda HospitalASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Matteo Origi
- Department of General SurgeryNiguarda HospitalASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Gaya Spolverato
- First Surgical Clinic SectionDepartment of Surgery, Oncology, and GastroenterologyUniversity of PadovaPadovaItaly
| | - Matteo Zuin
- First Surgical Clinic SectionDepartment of Surgery, Oncology, and GastroenterologyUniversity of PadovaPadovaItaly
| | - Sung Uk Bae
- Division of Colorectal SurgeryDepartment of SurgerySchool of MedicineKeimyung University and Dongsan Medical CentreDaeguKorea
| | - Seong Kyu Baek
- Division of Colorectal SurgeryDepartment of SurgerySchool of MedicineKeimyung University and Dongsan Medical CentreDaeguKorea
| | | | | | - Gyung Mo Son
- Department of SurgeryPusan National University Yangsan HospitalSchool of MedicinePusan National UniversityYangsanKorea
| | - Andrea Scala
- Department of Colorectal and Minimal Access SurgeryRoyal Surrey NHS Foundation TrustGuildfordUK
| | - Timothy Rockall
- Department of Colorectal and Minimal Access SurgeryRoyal Surrey NHS Foundation TrustGuildfordUK
| | - David W. Larson
- Division of Colon and Rectal SurgeryDepartment of SurgeryMayo ClinicRochesterMinnesotaUSA
| | - Alfredo Guglielmi
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynecology and PediatricsUniversity of VeronaVeronaItaly
| | - Gyu Seog Choi
- Colorectal Cancer CentreKyungpook National University Medical CentreSchool of MedicineKyungpook National UniversityDaeguKorea
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10
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Crippa J, Spinelli A. Evolving management strategies for perianal Crohn's fistulizing disease. Br J Surg 2021; 109:147-149. [PMID: 34849587 DOI: 10.1093/bjs/znab398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022]
Abstract
This is a review of perianal Crohn's disease providing insights into diagnostic, medical, and surgical pathways.
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Affiliation(s)
- Jacopo Crippa
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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11
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Mari G, Crippa J, Montroni I, Maggioni D, Calini G, Totis M, Tamini N, Oldani M, Cocozza E, Berselli M, Borroni G, Magistro C, Ferrari G, Achilli P, Petri R, Ziccarelli A, Crestale S, Bagnardi V, Peveri G, Origi M. MRI-Pathology Agreement in Rectal Cancer: Real-World Data from a Prospective Rectal Cancer Registry. Chirurgia (Bucur) 2021; 116:583-590. [PMID: 34749854 DOI: 10.21614/chirurgia.116.5.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 11/23/2022]
Abstract
Introduction: Magnetic Resonance Imaging (MRI) is routinely used in preoperative rectal cancer staging. The concordance of MRI staging with final pathologic exam, albeit improved, has not yet reached perfection. The aim of this study is to analyze the agreement between MRI and pathologic exam in patients operated on for mid-low rectal cancer. Material and Method: Patients undergoing neoadjuvant chemoradiation therapy (nCRT) or upfront surgery were analyzed. Between January 2019 to December 2019, 140 patients enrolled in the AIMS Academy rectal cancer registry were analyzed. Sixty-two patients received nCRT and 78 underwent upfront surgery. Results: Overall, the agreement between MRI and pathologic exam on T stage and N stage were 64.7% and 69.2%, respectively. The agreement between MRI and pathologic exam on T stage was 62.7% for patients who did not receive nCRT and 67.4% for patients who received nCRT (p = 0.62). The agreement on N stage was 76.3% for patients who did not receive nCRT and 60.0% for patients who received nCRT (p = 0.075). Conclusions: Real-world data shows MRI is still far from being able to correlate with the pathology findings which raises questions about the accuracy of the real-life decision-making process during cancer boards.
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12
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Carrano FM, Maroli A, Carvello M, Foppa C, Sacchi M, Crippa J, Clerico G, De Lucia F, Coppola E, Ben David N, Spinelli A. Negative-pressure wound therapy after stoma reversal in colorectal surgery: a randomized controlled trial. BJS Open 2021; 5:6460900. [PMID: 34904647 PMCID: PMC8669787 DOI: 10.1093/bjsopen/zrab116] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/19/2021] [Indexed: 11/14/2022] Open
Abstract
Background Stoma-reversal surgery is associated with high postoperative morbidity, including wound complications and surgical-site infections (SSIs). This study aims to assess whether the application of negative-pressure wound therapy (NPWT) can improve wound healing compared with conventional wound dressing. Methods This was a single-centre, superiority, open-label, parallel, individually randomized controlled trial. Patients undergoing stoma reversal were randomized (1 : 1) to receive NPWT or conventional wound dressing. The primary endpoint of the study was the rate of wound complications and SSIs after stoma closure. The secondary endpoints were postoperative wound pain, rate of wound healing after 30 days from stoma closure, and wound aesthetic satisfaction. Results Between June 2019 and January 2021, 50 patients were allocated to the NPWT group (all received NPWT, 49 were analysed); 50 patients were allocated to the conventional wound dressing group (48 received the treatment, 45 were analysed). No significant difference was found in wound-complication rate (10 per cent NPWT versus 16 per cent controls; odds ratio 0.61 (95 per cent c.i. 0.18 to 2.10), P = 0.542) and incisional SSI rate (8 per cent NPWT versus 7 per cent controls; odds ratio 1.24 (95 per cent c.i. 0.26 to 5.99), P = 1.000). The NPWT group showed less pain, higher aesthetic satisfaction (P < 0.0001), and a higher proportion of wound healing (92 versus 78 per cent; P = 0.081) compared with the control group. Conclusion NPWT does not reduce the incidence of SSI after stoma-reversal surgery compared with conventional wound dressing. However, NPWT improved the healing of uninfected wounds, reduced wound pain and led to better aesthetic outcomes. Registration number: NCT037812016 (clinicaltrials.gov).
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Affiliation(s)
- Francesco M Carrano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Annalisa Maroli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matteo Sacchi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Jacopo Crippa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giuseppe Clerico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesca De Lucia
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Elisabetta Coppola
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Nadav Ben David
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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13
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Origi M, Achilli P, Calini G, Costanzi A, Monteleone M, Montroni I, Maggioni D, Cocozza E, Megna S, Totis M, Tamini N, Ziccarelli A, Filippone G, Ferrari G, Crippa J, Spinelli A, Mari GM. The Diverticular Disease Registry (DDR Trial) by the Advanced International Mini-Invasive Surgery Academy Clinical Research Network: Protocol for a Multicenter, Prospective Observational Study. Int J Surg Protoc 2021; 25:194-200. [PMID: 34541429 PMCID: PMC8415185 DOI: 10.29337/ijsp.157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/28/2021] [Indexed: 01/16/2023] Open
Abstract
Diverticular disease is an increasingly common issue, with a variety of clinical presentations and treatment options. However, very few prospective cohort studies explore outcomes between the different presentations and treatments. The Diverticular Disease Registry (DDR Trial) is a multicenter, prospective, observational cohort study on behalf of the Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network. The DDR Trial aims to investigate the short-term postoperative and long-term quality of life outcomes in patients undergoing surgery or medical treatments for diverticular disease. DDR Trial is open to participation by all tertiary-care hospitals. DDR Trial has been registered at ClinicalTrials.gov (NCT04907383). Data collection will be recorded on Research Electronic Data Capture (REDCap) starting on June 1st, 2021 and will end after 5 years of recruitment. All adult patients with imaging-proven colonic diverticular disease (i.e., symptomatic colonic diverticulosis including diverticular bleeding, diverticulitis, and Symptomatic Uncomplicated Diverticular Disease) will be included. The primary outcome of DDR Trial is quality of life assessment at 12-month according to the Gastrointestinal Quality of Life Index (GIQLI). The secondary outcome is 30-day postoperative outcomes according to the Clavien-Dindo classification. DDR Trial will significantly advance in identifying the optimal care for patients with diverticular disease by exploring outcomes of different presentations and treatments. Highlights Diverticular disease (i.e., diverticulitis, bleeding) has different treatments.This is a clinical protocol for the Diverticular Disease Registry (DDR Trial).DDR Trial is a multicenter, prospective, observational cohort study open to participation.DDR Trial will study short-term postoperative and long-term quality of life outcomes.Medical treatments, interventional radiology and surgery will be explored.
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Affiliation(s)
- Matteo Origi
- General Surgery Department, Niguarda Hospital, Milano, Italy
| | - Pietro Achilli
- General Surgery Department, Niguarda Hospital, Milano, Italy
| | - Giacomo Calini
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Andrea Costanzi
- General Surgery Department, Merate Hospital, ASST Lecco, Italy
| | | | - Isacco Montroni
- General Surgery Department, Ospedale degli Infermi, Faenza, Italy
| | - Dario Maggioni
- General Surgery Department, Desio Hospital, ASST Brianza, Italy
| | | | | | - Mauro Totis
- General Surgery Department, ASST Monza, Italy
| | | | | | | | | | - Jacopo Crippa
- Humanitas Research Hospital, IRCCS, Rozzano - Milano, Italy
| | - Antonino Spinelli
- Humanitas Research Hospital, IRCCS, Rozzano - Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milano, Italy
| | - Giulio M Mari
- General Surgery Department, Desio Hospital, ASST Brianza, Italy
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14
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Mazzola M, Giani A, Crippa J, Morini L, Zironda A, Bertoglio CL, De Martini P, Magistro C, Ferrari G. Totally Laparoscopic Pancreaticoduodenectomy: Comparison Between Early and Late Phase of an Initial Single-Center Learning Curve. Indian J Surg Oncol 2021; 12:688-698. [DOI: 10.1007/s13193-021-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 08/09/2021] [Indexed: 12/25/2022] Open
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15
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Mari GM, Crippa J, Pietro A, Maggioni D, Costanzi A, Scotti MA, Braga M, Cocozza E, Borroni G, Benzoni I, Totaro L, Origi M, Ferrari G, Ziccarelli A, Petri R, Bagnardi V. Is BMI a Factor in Compliance to Adjuvant Chemotherapy for Locally Advanced Rectal Cancer? Chirurgia (Bucur) 2021; 116:51-59. [PMID: 33638326 DOI: 10.21614/chirurgia.116.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/23/2022]
Abstract
Background: Compliance to adjuvant chemotherapy (AC) for patients undergoing rectal surgery ranges from 43% to 73.6%. Reasons reported for not initiating or completing AC include onset of postoperative complications, drug toxicity, disease progression and/or patient preferences. Little is known regarding the impact of obesity on the compliance to AC in this setting.
Methods: This multicenter, retrospective study analyzed compliance to AC and treatment-related morbidity in 511 patients having undergone surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017.
Results: 70 patients were obese (BMI 30 kg/m2). The proportion of open procedures (22.9% vs. 13.4%) and conversions (14.3% vs. 4.8%) was greater in obese compared to non-obese patients (p 0.001). Median hospital stay was one day longer for obese patients (9 days vs. 10 days, p=0.038) while there was no statistically significant difference in the complication rate, whether overall (58.6% in obese vs. 52.3% in non-obese) or with a Clavien-Dindo score 3 (17.1% vs 10.9%). AC was offered to 49/70 (70%) patients in the obese group and 306/441 (69.4%) in the non-obese group (p=0.43). There was no statistically significant difference in AC compliance: 18.4% and 22.9% did not start AC, while 36.7% and 34.6%, started AC but did not complete the scheduled treatment (p=0.79) in the obese and non-obese group, respectively. Overall, 55% of patients who started AC successfully completed their adjuvant treatment.
Conclusions: Obesity did not impact compliance to AC for locally advanced rectal cancer: compliance was poor in obese and non-obese patients with no statistically significant difference between the two groups. Major complication rate was not statistically significantly affected by increased BMI.
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16
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Grass F, Hübner M, Crippa J, Lovely JK, Huebner M, Larson DW. Temporal patterns of hospital readmissions according to disease category for patients after elective colorectal surgery. J Eval Clin Pract 2021; 27:218-222. [PMID: 32212421 DOI: 10.1111/jep.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions. METHODS Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011-2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30-day readmissions (to index facility) including timing and reasons was utilized. The ICD-9 codes were regrouped into the main pathologies Cancer, Crohn's disease (CD)/chronic ulcerative colitis (CUC), and diverticular disease. RESULTS In total, 521 (7.2%) out of 7245 patients undergoing inpatient colorectal surgery were readmitted. In all increments of time from discharge (0-2 days: 31.3% of all readmissions, 3-7 days: 32.4% of all readmissions, 8-14 days: 18% of all readmissions, and 15-30 days: 18.3% of all readmissions), reasons for readmission differed significantly (all P < 0.001). Across all disease categories, early readmissions (within 2 days of discharge) were most likely due to ileus/obstruction (53.4% of early readmissions), whereas with 42.5%, infection was the most common cause for late readmissions (>7 days). Patients with home discharge were more likely to be readmitted earlier within the 30-day observation period (P = 0.099), whereas patients with a longer length of index hospital stay (>7 days) were readmitted later (P = 0.080). CONCLUSIONS Reasons for readmission appear to be universal across different disease categories. Targeted educational and collaborative measures may help to mitigate the burden of hospital readmissions to index facilities.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Marianne Huebner
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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17
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Crippa J, Grass F, Achilli P, Behm KT, Mathis KL, Day CN, Harmsen WS, Mari GM, Larson DW. Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database. Dis Colon Rectum 2021; 64:284-292. [PMID: 33555708 DOI: 10.1097/dcr.0000000000001887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies. OBJECTIVE This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted using a nationwide cohort. PATIENTS A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015). MAIN OUTCOME MEASURES Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge. RESULTS Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses. LIMITATIONS This study was limited by its retrospective design. CONCLUSION Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454. ABORDAJE QUIRRGICO DEL CNCER DE COLON TRANSVERSO ANLISIS DE LA PRCTICA ACTUAL Y LOS RESULTADOS ONCOLGICOS UTILIZANDO LA BASE DE DATOS NACIONAL DE CNCER ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.
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Affiliation(s)
- Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin T Behm
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Courtney N Day
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota
| | - Giulio M Mari
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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18
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Crippa J, Carvello M, Kotze PG, Spinelli A. Robotic Surgery in Inflammatory Bowel Disease. Curr Drug Targets 2020; 22:112-116. [PMID: 33109059 DOI: 10.2174/1389450121999200820125918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/06/2020] [Accepted: 07/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgery is considered a cornerstone of inflammatory bowel disease (IBD) treatment. In the last years, robotic surgery has seen an increase in adoption rates for both benign and malignant diseases. OBJECTIVE This work aims to review the current applications of robotic surgery in IBD. DISCUSSION AND CONCLUSION Minimally-invasive techniques have been applied to the treatment of IBD for more than 20 years. Investments in surgical digital and robotic platforms are increasingly arising, with an estimate of getting doubled within the next 5 years. Robotic surgery represents the newest technology available to reduce the impact of surgery on patients affected by IBD, and may theoretically be even more effective than other minimally-invasive techniques given the lower rate of conversion to open surgery as compared to laparoscopy according to many large retrospective series. Data on robotic surgery applied to IBD are still scarce and initial experiences in high-volume centers from retrospective series suggested that robotic surgery may achieve similar results when compared to laparoscopy. A new wave of robotics incorporating artificial intelligence is awaited to empower the capability of IBD surgeon in terms of intraoperative decision-making beyond technical skill enhancement.
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Affiliation(s)
- Jacopo Crippa
- General surgery residency program, University of Milan, Milan, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Paulo Gustavo Kotze
- IBD outpatient clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
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19
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Pedrazzani C, Turri G, Park SY, Hida K, Fukui Y, Crippa J, Ferrari G, Origi M, Spolverato G, Zuin M, Bae SU, Baek SK, Costanzi A, Maggioni D, Son GM, Scala A, Rockall T, Guglielmi A, Choi GS, Larson DW. Clinical-Pathologic Characteristics and Long-term Outcomes of Left Flexure Colonic Cancer: A Retrospective Analysis of an International Multicenter Cohort. Dis Colon Rectum 2020; 63:1593-1601. [PMID: 33149021 DOI: 10.1097/dcr.0000000000001785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal cancer seldom presents at the splenic flexure. Small series on left flexure tumors reported a high occurrence of negative prognostic factors called into question as causes of poor prognosis. However, because of the small number of cases, no definite conclusions can be drawn. OBJECTIVE The aim of this study was to compare clinical-pathologic characteristics and short- and long-term outcomes of left flexure tumors with other colonic locations. DESIGN This was a retrospective analysis of consecutive patients who underwent surgery for tumors at the splenic flexure. Each tumor was paired in a 1 to 1 fashion with a right-sided and sigmoid tumor. SETTINGS The study was conducted in 10 international centers. PATIENTS A total of 641 patients with left flexure tumors were included in the study. MAIN OUTCOME MEASURES Overall survival and cancer-specific survival were measured. RESULTS Left flexure tumors presented more frequently with stenosis (30.5%; p < 0.001), with lesions infiltrating beyond the serosa (21.9%; p = 0.001) and with a high rate of mucinous histology (8.8%; p = 0.001). Looking at long-term prognosis, no differences were observed among the 3 groups, both considering overall and cancer-specific survival. However, left flexure tumors recurred more frequently as peritoneal carcinomatosis (20.6%; p < 0.001). LIMITATIONS This study was limited because of its retrospective nature. CONCLUSIONS Although left flexure tumors display several negative prognostic factors, they are not characterized by a worse prognosis compared with other colon cancer locations. See Video Abstract at http://links.lww.com/DCR/B395. CARACTERÍSTICAS CLÍNICO-PATOLÓGICAS Y RESULTADOS A LARGO PLAZO DEL CÁNCER DE COLON DE ÁNGULO IZQUIERDO: UN ANÁLISIS RETROSPECTIVO DE UNA COHORTE MULTICÉNTRICA INTERNACIONAL: El cáncer colorrectal rara vez se presenta en el ángulo esplénico. Pequeñas series sobre tumores de ángulo izquierdo informaron una alta incidencia de factores pronósticos negativos cuestionados como causas de mal pronóstico. Sin embargo, debido al pequeño número de casos, no se pueden sacar conclusiones definitivas.El objetivo de este estudio fue comparar las características clínico-patológicas, los resultados a corto y largo plazo de los tumores de ángulo izquierdo con otras ubicaciones de colon.Análisis retrospectivo de pacientes consecutivos que se sometieron a cirugía por tumores en el ángulo esplénico. Cada tumor se emparejó de forma individual con un tumor del lado derecho y sigmoide.El estudio se realizó en 10 centros internacionales.Se incluyeron en el estudio un total de 641 pacientes con tumores del ángulo izquierdo.Supervivencia general y específica del cáncerLos tumores de ángulo izquierda se presentaron con mayor frecuencia con estenosis (30.5%, p <0.001), con lesiones infiltradas más allá de la serosa (21.9%, p = 0.001), y con una alta tasa de histología mucinosa (8.8%, p = 0.001). En cuanto al pronóstico a largo plazo, no se observaron diferencias entre los tres grupos, considerando la supervivencia general y específica del cáncer. Sin embargo, los tumores de ángulo izquierdo recurrieron con mayor frecuencia como carcinomatosis peritoneal (20,6%; p <0,001).Este estudio fue limitado debido a su naturaleza retrospectiva.Aunque los tumores de ángulo izquierdo muestran varios factores pronósticos negativos, no se caracterizan por un peor pronóstico en comparación con otras ubicaciones de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B395.
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Affiliation(s)
- Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Giulia Turri
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yudai Fukui
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jacopo Crippa
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Giovanni Ferrari
- Department of General Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Origi
- Department of General Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gaya Spolverato
- First Surgical Clinic Section, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Matteo Zuin
- First Surgical Clinic Section, Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Sung Uk Bae
- Division of Colorectal Surgery, Department of Surgery, School of Medicine, Keimyung University and Dongsan Medical Center, Daegu, Korea
| | - Seong Kyu Baek
- Division of Colorectal Surgery, Department of Surgery, School of Medicine, Keimyung University and Dongsan Medical Center, Daegu, Korea
| | - Andrea Costanzi
- General Surgery Unit, San Leopoldo Mandic Hospital Merate, ASST Lecco, Italy
| | - Dario Maggioni
- General Surgery Unit, San Leopoldo Mandic Hospital Merate, ASST Lecco, Italy
| | - Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Korea
| | - Andrea Scala
- Department of Colorectal and Minimal Access Surgery, Royal Surrey National Health Service Foundation Trust, Guildford, United Kingdom
| | - Timothy Rockall
- Department of Colorectal and Minimal Access Surgery, Royal Surrey National Health Service Foundation Trust, Guildford, United Kingdom
| | - Alfredo Guglielmi
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
| | - Gyu Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - David W Larson
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Mari GM, Crippa J, Achilli P, Montroni I, Ugolini G, Taffurelli G, Cocozza E, Borroni G, Valenti F, Roscio F, Ferrari G, Origi M, Zuliani W, Pugliese R, Costanzi ATM, Fingherut A, Maggioni D. High Versus Low Ligation of the Inferior Mesenteric Artery During Rectal Resection for Cancer: Oncological Outcomes After Three Years of Follow-Up From the HIGHLOW Trial. Ann Surg Open 2020; 1:e017. [PMID: 37637440 PMCID: PMC10455194 DOI: 10.1097/as9.0000000000000017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/03/2020] [Indexed: 11/27/2022] Open
Abstract
Objectives To determine the disease-free survival (DFS), disease-specific survival (DSS), and recurrence in patients who underwent laparoscopic low anterior rectal resection with total mesorectal excision (TME) with either high or low ligation of the inferior mesenteric artery (IMA). Background The level of IMA ligation during anterior rectal resection with TME is still a matter of debate, especially in terms of oncological adequacy. Methods Between June 2014 and December 2016, patients scheduled to undergo elective laparoscopic low anterior resection (LAR) and TME in 6 Italian nonacademic hospitals were randomized into 2 groups in the HIGHLOW Trial (ClinicalTrials.gov Identifier: NCT02153801) according to the level of IMA ligation: high ligation (HL) versus low ligation (LL). DFS, DSS, and recurrence were inquired. Recurrence was determined at 3, 6, 9, and 12 months and every 6 months thereafter. Patients and tumor characteristics as well as surgical outcomes were analyzed to identify risk factors for recurrence. Results One hundred ninety-six patients from the HIGHLOW trial were analyzed. Median follow-up for DFS was 40.6 (interquartile range [IQR], 6-64.7) and 40 (IQR, 7.6-67.8), while median follow-up for DSS was 41.2 (IQR, 10.7-64.7) and 42.7 (IQR, 6-67.6) in the HL and LL groups, respectively. The 3-year DFS rate of HL and LL patients was 82.2% and 82.1% (P = 0.874), respectively. The 3-year DSS for HL and LL patients was 92.1% and 93.4% (P = 0.897), respectively. There was no statistically significant difference in the local recurrence rate (2% HL vs 2.1% LL), in the regional recurrence rate (3% HL vs 2.1% LL), and in the distant recurrence rate (12.9% HL vs 13.7% LL). Multivariate analysis found conversion to open surgery (hazard ratio [HR], 3.68; P = 0.001) and higher stage of disease (HR, 7.73; P < 0.001) to be significant determinant for DFS. Conclusions The level of inferior mesenteric artery ligation during LAR and TME for rectal cancer does not affect DFS, DSS, and recurrence.
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Affiliation(s)
- Giulio M. Mari
- From the Laparoscopic and Oncological General Surgery Department, ASST Monza, Desio Hospital, Desio MB, Italy
| | - Jacopo Crippa
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Pietro Achilli
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Isacco Montroni
- Colorectal Surgery, Department of Surgery, Ospedale per gli Infermi Faenza, Faenza, Italy
| | - Giampaolo Ugolini
- Colorectal Surgery, Department of Surgery, Ospedale per gli Infermi Faenza, Faenza, Italy
| | - Giovanni Taffurelli
- Colorectal Surgery, Department of Surgery, Ospedale per gli Infermi Faenza, Faenza, Italy
| | - Eugenio Cocozza
- ASST Sette Laghi, Surgical Oncology and Minimally Invasive Unit, Varese, Italy
| | - Giacomo Borroni
- ASST Sette Laghi, Surgical Oncology and Minimally Invasive Unit, Varese, Italy
| | | | - Francesco Roscio
- Division of General Surgery, ASST Sette Laghi, Galmarini Hospital, Tradate VA, Italy
| | - Giovanni Ferrari
- Division of Oncologic and Mini-Invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Origi
- Division of Oncologic and Mini-Invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Walter Zuliani
- Humanitas Mater Domini Clinical Institute, General Surgery, Castellanza VA, Italy
| | | | - Andrea T. M. Costanzi
- General Surgery Department, ASST Lecco, San Leopoldo Mandic Hospital, Merate, Italy; and
| | - Abe Fingherut
- Surgical Research, Department of Surgery, Medical University of Graz, Austria and Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, People’s Republic of China
| | - Dario Maggioni
- From the Laparoscopic and Oncological General Surgery Department, ASST Monza, Desio Hospital, Desio MB, Italy
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21
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Mazzola M, Giani A, Crippa J, Morini L, Zironda A, Bertoglio CL, De Martini P, Magistro C, Ferrari G. Totally laparoscopic versus open pancreaticoduodenectomy: A propensity score matching analysis of short-term outcomes. Eur J Surg Oncol 2020; 47:674-680. [PMID: 33176959 DOI: 10.1016/j.ejso.2020.10.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Laparoscopic pancreaticoduodenectomy (LPD) is a demanding operation that has not yet gained popularity. Safety, feasibility, and clinical advantages of LPD in comparison with open pancreaticoduodenectomy (OPD) have not been clearly demonstrated. The aim of this study was to compare the short term outcomes of LPD with those of OPD. MATERIAL AND METHODS Data from a prospectively collected database of patients who underwent pancreaticoduodenectomy at our institution between January 2013 and March 2020 were retrieved and analyzed, comparing the short-term postoperative outcomes of LPD and OPD, using a propensity score matching analysis. RESULTS In the study period, 177 patients undergoing pancreaticoduodenectomy were selected, 52 of these were LPD. In the LPD group, the conversion rate to OPD was 3.8%. After matching, a total of 50 LPD and 50 OPD were compared. LPD was associated with a shorter length of stay (14 vs 20 days, p = 0.011), decreased blood loss (255 vs 350 ml, p = 0.022), but longer median operative time (590 vs 382.5 min; p < 0.001). No significant difference was found between LPD and OPD in terms of overall complications (56% vs 62%, p = 0.542), severe complications (26% vs 22%, p = 0.640), and postoperative mortality (4% vs 6%, p = 0.646). The groups had similar reoperation rate, pancreatic-specific complications, and readmission rate. CONCLUSIONS In comparison with the open approach, LPD seems associated to with improved short-term outcomes in terms of hospital stay and blood loss, but with a longer operative time. No difference in morbidity and mortality rate were found in our series.
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Affiliation(s)
- Michele Mazzola
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy.
| | - Alessandro Giani
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Jacopo Crippa
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Lorenzo Morini
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Andrea Zironda
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Camillo L Bertoglio
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Paolo De Martini
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Carmelo Magistro
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Giovanni Ferrari
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
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Mari G, Achilli P, Crippa J, Cordaro G, Berardi V, Di Fratta E, Maggioni D. Laparoscopic treatment of diffuse peritonitis for ileocolic anastomotic leak following totally laparoscopic right hemicolectomy. Surg Pract 2020. [DOI: 10.1111/1744-1633.12461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Giulio Mari
- Department of General Surgery Desio Hospital Desio (MB) Italy
| | - Pietro Achilli
- University of Milan, General Surgery Residency Program Milan Italy
| | - Jacopo Crippa
- University of Milan, General Surgery Residency Program Milan Italy
| | - Giuseppe Cordaro
- University of Milan, General Surgery Residency Program Milan Italy
| | - Valter Berardi
- Department of General Surgery Desio Hospital Desio (MB) Italy
| | | | - Dario Maggioni
- Department of General Surgery Desio Hospital Desio (MB) Italy
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23
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Achilli P, Crippa J, Grass F, Larson DW. Reply to: Comments on "Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database". Int J Cancer 2020; 148:1028-1029. [PMID: 33034382 DOI: 10.1002/ijc.33256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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24
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Achilli P, Crippa J, Grass F, Mathis KL, D'Angelo ALD, Abd El Aziz MA, Day CN, Harmsen WS, Larson DW. Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database. Int J Cancer 2020; 148:161-169. [PMID: 32638371 DOI: 10.1002/ijc.33203] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022]
Abstract
Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.
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Affiliation(s)
- Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Courtney N Day
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota, USA
| | - William S Harmsen
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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25
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Maspero M, Mazzola M, Bertoglio CL, Crippa J, Morini L, Magistro C, De Martini P, Gualtierotti M, Lombardi PM, Ferrari G. Major cancer surgery during the coronavirus pandemic: experience from a tertiary referral center and COVID-19 hub in Northern Italy. Br J Surg 2020; 107:e440-e441. [PMID: 32757214 PMCID: PMC7436416 DOI: 10.1002/bjs.11892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 11/22/2022]
Affiliation(s)
- M Maspero
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - M Mazzola
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - C L Bertoglio
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - J Crippa
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - L Morini
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - C Magistro
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - P De Martini
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - M Gualtierotti
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - P M Lombardi
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - G Ferrari
- Division of Oncological and Minimally Invasive General Surgery, ASST Grande Ospedale Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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Mazzola M, Crippa J, Bertoglio CL, Andreani S, Morini L, Sfondrini S, Ferrari G. Postoperative risk of pancreatic fistula after distal pancreatectomy with or without spleen preservation. Tumori 2020; 107:160-165. [PMID: 32635820 DOI: 10.1177/0300891620936744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Outcomes after distal pancreatectomy with or without splenectomy are controversial. The present study aims to investigate differences in short-term and long-term outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). METHODS In this retrospective review of consecutive patients undergoing distal pancreatectomy with or without splenectomy from January 2011 until December 2017 for benign disease, the primary endpoint was to compare postoperative pancreatic fistula (POPF). The secondary endpoint was to compare duration of surgery, intraoperative blood loss, postoperative complications, length of hospital stay, and long-term outcomes. RESULTS Patients undergoing SPDP had a lower rate of POPF (13.6% vs 46.1%; p = 0.02). Patients undergoing SPDP (n = 22) were discharged earlier than patients undergoing DPS (n = 26) (8 [4-29] vs 12 [6.48] days; p = 0.003). No differences in other intraoperative and postoperative outcomes were found between groups. CONCLUSION Patients undergoing SPDP developed fewer POPF and were discharged earlier compared to patients undergoing DPS.
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Affiliation(s)
- Michele Mazzola
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Jacopo Crippa
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Camillo L Bertoglio
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Sara Andreani
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lorenzo Morini
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Sfondrini
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Ferrari
- Division of Oncologic and Minimally-invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Abstract
BACKGROUND Anastomotic leak remains a critical complication after restorative rectal cancer surgery and is associated with significant morbidity and mortality rates, whereas reported rates range from 4% to 29%. Whether the occurrence of leak may have an impact on long-term oncological outcomes is under debate. OBJECTIVE This study aimed to describe the oncological impact of anastomotic leak on patients undergoing sphincter-preserving surgery for rectal adenocarcinoma. DESIGN This is a retrospective review of a prospectively maintained database. SETTINGS The study was conducted at a high-volume colorectal center. PATIENTS Data on patients who underwent restorative surgery for rectal adenocarcinoma from January 2000 until December 2013 were retrospectively analyzed. MAIN OUTCOME MEASURES The primary outcome measured was the impact of anastomotic leak, defined according to the classification proposed by the International Study Group of Rectal Cancer, on long-term overall survival, disease-free survival, disease-specific survival, and local recurrence. RESULTS A total of 787 patients undergoing sphincter-preserving surgery for rectal cancer met the inclusion criteria. Forty-two (5.3%) patients presented a symptomatic anastomotic leak. The median follow-up period was 64 months. Fifty-one (6.5%) patients experienced a cancer-related death, 2 of 42 in the anastomotic leak group. Five-year overall survival, disease-specific survival, and disease-free survival were 88%, 94.7%, and 85.3%. Local recurrence rate was 2%. There was no difference in long-term overall survival, disease-specific survival, disease-free survival, and local recurrence rate between groups. On a multivariable analysis, anastomotic leak did not impact oncological outcomes. LIMITATIONS This study was limited by retrospective analysis. CONCLUSIONS The occurrence of anastomotic leak after restorative resection for rectal cancer did not impact long-term oncological outcomes in our cohort of patients. See Video Abstract at http://links.lww.com/DCR/B187. RESULTADOS ONCOLÓGICOS A LARGO PLAZO DESPUÉS DE UNA FUGA ANASTOMÓTICA EN CIRUGÍA DE CÁNCER RECTAL: La fuga anastomótica sigue siendo una complicación crítica después de la cirugía restauradora del cáncer rectal y se asocia con tasas significativas de morbilidad y mortalidad, mientras que las tasas reportadas varían del 4% al 29%. Se está debatiendo si la aparición de fugas puede tener un impacto en los resultados oncológicos a largo plazo.Describir el impacto oncológico de la fuga anastomótica en pacientes sometidos a cirugía de preservación del esfínter para adenocarcinoma rectal.Revisión retrospectiva de una base de datos mantenida prospectivamente.El estudio se realizó en un centro colorrectal de alto volumen.Se analizaron retrospectivamente los datos de pacientes que se sometieron a cirugía reparadora por adenocarcinoma rectal desde Enero de 2000 hasta Diciembre de 2013.Impacto de la fuga anastomótica, definida de acuerdo con la clasificación propuesta por el Grupo de Estudio Internacional del Cáncer Rectal (International Study Group of Rectal Cancer), sobre la supervivencia general a largo plazo, la supervivencia libre de enfermedad, la supervivencia específica de la enfermedad y la recurrencia local.Un total de 787 pacientes sometidos a cirugía para preservar el esfínter por cáncer rectal cumplieron con los criterios de inclusión. Cuarenta y dos (5.3%) pacientes presentaron una fuga anastomótica sintomática. El tiempo mediano del período de seguimiento fue de 64 meses. Cincuenta y un (6.5%) pacientes sufrieron muerte relacionada con el cáncer, 2 de 42 en el grupo de fuga anastomótica. La supervivencia global a cinco años, la supervivencia específica de la enfermedad y la supervivencia libre de enfermedad fueron del 88%, 94.7% y 85.3%, respectivamente. La tasa de recurrencia local fue del 2%. No hubo diferencias en la supervivencia global a largo plazo, la supervivencia específica de la enfermedad, la supervivencia libre de enfermedad y la tasa de recurrencia local entre los grupos. En un análisis multivariable, la fuga anastomótica no afectó los resultados oncológicos.Este estudio fue limitado por análisis retrospectivo.La aparición de fuga anastomótica después de la resección restauradora para el cáncer rectal no afectó los resultados oncológicos a largo plazo en nuestra cohorte de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B187. (Traducción-Dr. Yesenia Rojas-Kahlil).
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Affiliation(s)
- Jacopo Crippa
- Division of Colon & Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Emilie Duchalais
- Division of Colon & Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Amit Merchea
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, Florida
| | - Scott R Kelley
- Division of Colon & Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Division of Colon & Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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28
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Mari GM, Crippa J, Casciaro F, Maggioni D. A 10-step guide to convert a surgical unit into a COVID-19 unit during the COVID-19 pandemic. Int J Surg 2020; 78:113-114. [PMID: 32353555 PMCID: PMC7185019 DOI: 10.1016/j.ijsu.2020.04.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Giulio M Mari
- General Surgery Department, Desio Hospital, ASST Monza, Viale Mazzini 1, 20832, Desio, MB, Italy
| | - Jacopo Crippa
- University of Milan, Via Festa Del Perdono, 7 20116, Milan, Italy.
| | - Franco Casciaro
- General Surgery Department, Desio Hospital, ASST Monza, Viale Mazzini 1, 20832, Desio, MB, Italy
| | - Dario Maggioni
- General Surgery Department, Desio Hospital, ASST Monza, Viale Mazzini 1, 20832, Desio, MB, Italy
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29
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Crippa J, Grass F, Larson DW. Author response to: Is robotic approach associated with a lower risk of conversion in rectal cancer surgery compared with laparoscopic approach? Br J Surg 2020; 107:e227. [PMID: 32352562 DOI: 10.1002/bjs.11599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/07/2022]
Affiliation(s)
- J Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - F Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Girardi V, Barone G, Gualtierotti M, De Martini P, Mutignani M, Crippa J, Ferrari G. Laparoscopic Adjustable Gastric Band: Case Report of Erosion with Intragastric Migration Requiring an Extreme Surgical Approach. Obes Surg 2020; 30:2030-2032. [PMID: 32147776 DOI: 10.1007/s11695-020-04455-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- V Girardi
- Division of Minimally Invasive Oncologic Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - G Barone
- Division of Minimally Invasive Oncologic Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - M Gualtierotti
- Division of Minimally Invasive Oncologic Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - P De Martini
- Division of Minimally Invasive Oncologic Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - M Mutignani
- Digestive and Operative Endoscopy Unit, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - J Crippa
- Division of Minimally Invasive Oncologic Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy. .,General Surgery Residency Program, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy.
| | - G Ferrari
- Division of Minimally Invasive Oncologic Surgery, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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Grass F, Behm KT, Duchalais E, Crippa J, Spears GM, Harmsen WS, Hübner M, Mathis KL, Kelley SR, Pemberton JH, Dozois EJ, Larson DW. Impact of delay to surgery on survival in stage I-III colon cancer. Eur J Surg Oncol 2020; 46:455-461. [PMID: 31806516 DOI: 10.1016/j.ejso.2019.11.513] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/11/2019] [Accepted: 11/27/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer. METHODS National Cancer database (NCDB) analysis (2004-2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS. RESULTS Time to treatment was <16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p < 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05-1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days. CONCLUSION This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Department of Visceral Surgery, Lausanne University Hospital, Bugnon 46, 1011, Lausanne, Switzerland
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Emilie Duchalais
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Grant M Spears
- Department of Biostatistics, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital, Bugnon 46, 1011, Lausanne, Switzerland
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Mari GM, Crippa J, Achilli P, Miranda A, Santurro L, Riggio V, Gerosa M, Ascheri P, Cordaro G, Costanzi AT, Maggioni D. 4K ultra HD technology reduces operative time and intraoperative blood loss in colorectal laparoscopic surgery. F1000Res 2020; 9:106. [PMID: 32789007 PMCID: PMC7400694 DOI: 10.12688/f1000research.21297.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/26/2022] Open
Abstract
Background: HD systems are routinely used in laparoscopic surgery, 4K ultra HD monitors are mainly available within specialized, high-volume laparoscopic centers. The higher resolution of 4K ultra HD video could upgrade the surgical performance improving intraoperative and post-operative outcomes. Methods: We performed a retrospective comparative analysis of intraoperative parameters and post-operative outcomes in a cohort of patients operated on for elective laparoscopic procedures for colo-rectal cancer during two different time frames: 2017 procedures performed using the Visera Elite full HD technology (® Olympus America, Medical) and the 2018 procedures performed the Visera 4K Ultra HD System (® Olympus America, Medical). Results: There was a statistically significant reduction in operative time in patients operated on with the 4K ultra HD technology compared to HD technology (p < 0.05). Intraoperative blood loss was significantly reduced in patients operated in 2018 (p < 0.05). There were no statistically significant differences in complication rate and postoperative outcomes between the two groups.
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Affiliation(s)
- Giulio M. Mari
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Jacopo Crippa
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Pietro Achilli
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Angelo Miranda
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Letizia Santurro
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Valentina Riggio
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Martino Gerosa
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Pietro Ascheri
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Giuseppe Cordaro
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | | | - Dario Maggioni
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
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Crippa J, Grass F, Achilli P, Mathis KL, Kelley SR, Merchea A, Colibaseanu DT, Larson DW. Risk factors for conversion in laparoscopic and robotic rectal cancer surgery. Br J Surg 2020; 107:560-566. [PMID: 31976558 DOI: 10.1002/bjs.11435] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to review risk factors for conversion in a cohort of patients with rectal cancer undergoing minimally invasive abdominal surgery. METHODS A retrospective analysis was performed of consecutive patients operated on from February 2005 to April 2018. Adult patients undergoing low anterior resection or abdominoperineal resection for primary rectal adenocarcinoma by a minimally invasive approach were included. Exclusion criteria were lack of research authorization, stage IV or recurrent rectal cancer, and emergency surgery. Risk factors for conversion were investigated using logistic regression. A subgroup analysis of obese patients (BMI 30 kg/m2 or more) was performed. RESULTS A total of 600 patients were included in the analysis. The overall conversion rate was 9·2 per cent. Multivariable analysis showed a 72 per cent lower risk of conversion when patients had robotic surgery (odds ratio (OR) 0·28, 95 per cent c.i. 0·15 to 0·52). Obese patients experienced a threefold higher risk of conversion compared with non-obese patients (47 versus 24·4 per cent respectively; P < 0·001). Robotic surgery was associated with a reduced risk of conversion in obese patients (OR 0·22, 0·07 to 0·71). CONCLUSION Robotic surgery was associated with a lower risk of conversion in patients undergoing minimally invasive rectal cancer surgery, in both obese and non-obese patients.
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Affiliation(s)
- J Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - F Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - P Achilli
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - S R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - A Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - D T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Grass F, Lovely JK, Crippa J, Hübner M, Mathis KL, Larson DW. Potential Association Between Perioperative Fluid Management and Occurrence of Postoperative Ileus. Dis Colon Rectum 2020; 63:68-74. [PMID: 31633601 DOI: 10.1097/dcr.0000000000001522] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs. OBJECTIVE The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway. DESIGN This was a retrospective cohort study of a prospectively maintained institutional database. SETTINGS The study was conducted at a tertiary academic facility with fully implemented standardized enhanced recovery pathway over the entire study period. PATIENTS All of the consecutive elective major colorectal resections for benign or malign indications between 2011 and 2016 were included. MAIN OUTCOME MEASURES Postoperative ileus was defined as the need for nasogastric tube reinsertion. Perioperative fluid management and surgical outcome were compared between patients presenting with ileus and those without. Potential risk factors for ileus were identified through multinomial logistic regression. RESULTS Postoperative ileus occurred in 377 (9%) of 4205 included patients at day 4 (interquartile range, 2-5 d). Intraoperatively, ileus patients received 3.2 ± 2.6 L of fluids, whereas the remaining patients received 2.5 ± 1.7 L (p < 0.001). Weight gain was 3.8 ± 7.1 kg in ileus patients versus 3.0 ± 6.6 kg (p = 0.272) in the remaining patients at postoperative day 1, 4.4 ± 6.5 kg versus 3.1 ± 7.0 kg (p = 0.028) at postoperative day 2, and 1.8 ± 6.0 kg versus 0.0 ± 6.0 kg at discharge (p = 0.002). The multivariable model including all significant (p < 0.05) demographic, fluid management-related, and surgical parameters retained postoperative day 0 fluids of >3 L (OR = 1.65 (95% CI, 1.13-2.41); p = 0.009), postoperative day 2 weight gain of >2.5 kg (OR = 1.49 (95% CI, 1.01-2.21); p = 0.048), and occurrence of postoperative complications (OR = 2.00 (95% CI, 1.39-2.90); p < 0.001) as independent risk factors for ileus. LIMITATIONS This study was limited by its retrospective design. Fluid management depends on patient-, disease-, and surgery-related factors and cannot be generalized and extrapolated. CONCLUSIONS Fluid overload and occurrence of postoperative complications were independent risk factors for postoperative ileus. This calls for action to keep perioperative fluids below suggested thresholds. See Video Abstract at http://links.lww.com/DCR/B54. ASOCIACIÓN POTENCIAL ENTRE EL MANEJO DEL LÍQUIDO PERIOPERATORIO Y EL SUCESO DE ÍLEO POSTOPERATORIO: El íleo postoperatorio sigue siendo un problema después de una cirugía colorrectal que retrasa la recuperación y aumenta la duración de la estancia hospitalaria y los costos.Analizar el impacto del manejo del líquido perioperatorio en la incidencia de íleo después de la cirugía colorrectal dentro de una vía de recuperación mejorada totalmente implementada.Estudio de cohorte retrospectivo de una base de datos institucional mantenida prospectivamente.Centro académico terciario con una ruta de recuperación mejorada estandarizada completamente implementada durante todo el período del estudio.Se incluyeron todas las resecciones colorrectales mayores electivas consecutivas para indicaciones benignas o malignas entre 2011 y 2016.El íleo postoperatorio se definió como la necesidad de reinserción de la sonda nasogástrica. El manejo del líquido perioperatorio y el resultado quirúrgico se compararon entre los pacientes con íleo y los que no. Los posibles factores de riesgo para el íleo se identificaron mediante regresión logística multinominal.El íleo postoperatorio se ocurrió en 377 (9%) de los 4205 pacientes incluidos al cuarto día (RIC 2-5). Intraoperatoriamente, los pacientes con íleo recibieron 3.2 ± 2.6 L de líquidos, mientras que los pacientes restantes recibieron 2.5 ± 1.7 L (p < 0.001). El aumento de peso fue de 3.8 ± 7.1 kg en pacientes con íleo versus 3 ± 6.6 kg (p = 0.272) en los pacientes restantes en el día postoperatorio 1, 4.4 ± 6.5 kg vs. 3.1 ± 7 kg (p = 0.028) en el día postoperatorio 2 y 1.8 ± 6 kg versus a 0 ± 6 kg al tiempo de alta hospitalaria (p = 0.002). El modelo multivariable que incluye todos los parámetros demográficos, del manejo de líquidos y quirúrgicos significativos (p <0.05) mantuvo líquidos del día 0 después de la operación de> 3L (proporción de probabilidad 1.65, intervalo de confianza del 95% 1.13-2.41, p = 0.009), ganancia de peso de > 2.5 kg en el dia postoperatorio 2 (proporción de probabilidad 1.49, 95% intervalo de confianza 1.01-2.21, p = 0.048) y aparición de complicaciones postoperatorias (proporción de probabilidad 2, 95% intervalo de confianza 1.39-2.9, p <0.001) como factores de riesgo independientes para íleo.Diseño retrospectivo. El manejo de líquidos depende de factores relacionados con el paciente, la enfermedad y la cirugía, y no puede generalizarse ni extrapolarse.La sobrecarga de líquidos y la aparición de complicaciones postoperatorias fueron factores de riesgo independientes para el íleo postoperatorio. Esto requiere medidas para mantener los líquidos perioperatorios por debajo de los umbrales sugeridos. Vea el Video del Resumen en http://links.lww.com/DCR/B54.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Mazzola M, Morini L, Crippa J, Maspero M, Zironda A, Giani A, Martini PD, Ferrari G. Totally Laparoscopic Pancreaticoduodenectomy: Technical Notes. Chirurgia (Bucur) 2020; 115:385-393. [DOI: 10.21614/chirurgia.115.3.385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
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Mari GM, Achilli P, Maggioni D, Crippa J, Costanzi ATM, Scotti MA, Giardini V, Garancini M, Cocozza E, Borroni G, Benzoni I, Martinotti M, Totaro L, Origi M, Mazzola M, Ferrari G, Ziccarelli A, Petri R, Bagnardi V, Pugliese G, Forgione A, Pugliese R. Creation of a rectal cancer registry in Italy by the Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network. F1000Res 2019; 8:1736. [PMID: 31723425 PMCID: PMC6833985 DOI: 10.12688/f1000research.20702.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2019] [Indexed: 12/13/2022] Open
Abstract
Background: The management of rectal cancer is multimodal and involves a multidisciplinary team of cancer specialists with expertise in medical oncology, surgical oncology, radiation oncology and radiology. It is crucial for highly specialized centers to collaborate via networks that aim to maintain uniformity in every aspect of treatment and rigorously gather patients’ data, from the first clinical evaluation to the last follow-up visit. The Advanced International Mini-Invasive Surgery (AIMS) academy clinical research network aims to create a rectal cancer registry. This will prospectively collect the data of patients operated on for non-metastatic rectal cancer in high volume colorectal surgical units through a well design pre-fashioned database for non-metastatic rectal cancer, in order to take all multidisciplinary aspects into consideration. Methods/Design: The protocol describes a multicenter prospective observational cohort study, investigating demographics, frailty, cancer-related features, surgical and radiological parameters, and oncological outcomes among patients with non-metastatic rectal cancer who are candidates for surgery with curative intent. Patients enrolled in the present registry will be followed up for 5 years after surgery. Discussion: Standardization and centralization of data collection for neoplastic diseases is a virtuous process for patient care. The creation of a register will allow the control of the quality of treatments provided and permit prospective and retrospective studies to be carried out on complete and reliable high quality data. Establishing data collection in a prospective and systematic fashion is the only possibility to preserve the enormous resource that each patient represents.
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Affiliation(s)
- Giulio M Mari
- General Surgery Department, Desio Hospital, Desio, Italy
| | - Pietro Achilli
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Dario Maggioni
- General Surgery Department, Desio Hospital, Desio, Italy
| | - Jacopo Crippa
- General Surgery Residency Program, University of Milan, Milan, Italy
| | | | - Mauro A Scotti
- General Surgery Department, San Gerardo Hospital, Monza, Italy
| | | | | | | | | | | | | | - Luigi Totaro
- Department of Surgery, Cremona Hospital, Cremona, Italy
| | - Matteo Origi
- General Surgery Department, Niguarda Hospital, Milan, Italy
| | | | | | | | - Roberto Petri
- General Surgery Department, AOU "SSMM della Misericordia", Udine, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Giacomo Pugliese
- AIMS Academy Clinical Research Network, Advanced International Mini-Invasive Surgery (AIMS) Academy, Milan, Italy
| | | | - Raffaele Pugliese
- AIMS Academy Clinical Research Network, Advanced International Mini-Invasive Surgery (AIMS) Academy, Milan, Italy
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Mari GM, Maggioni D, Crippa J, Costanzi ATM, Scotti MA, Giardini V, Garancini M, Cocozza E, Borroni G, Benzoni I, Martinotti M, Totaro L, Origi M, Mazzola M, Ferrari G, Achilli P, Ziccarelli A, Martino A, Petri R, Botta F, Bagnardi V, Pugliese G, Forgione A, Pugliese R. Compliance to Adjuvant Chemotherapy of Patients Who Underwent Surgery for Rectal Cancer: Report from a Multi-institutional Research Network. World J Surg 2019; 43:2544-2551. [PMID: 31240433 DOI: 10.1007/s00268-019-05060-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Adjuvant chemotherapy for locally advanced rectal cancer is associated with improved overall survival. However, recent evidence from randomized trials showed a compliance rate of 43 to 73%, which may affect efficacy. The aim of this multicenter retrospective analysis was to investigate the compliance rate to adjuvant treatment for patients who underwent rectal surgery for cancer. METHODS Patients who underwent surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017 were retrospectively reviewed. Exclusion criteria were age less than 18 years, palliative or emergency surgery, and stage IV disease. Parameters of interest were patients' characteristics, preoperative tumor stage, neo-adjuvant chemoradiation therapy, intra-operative and postoperative outcomes. Although the participating centers referred to the same treatment guidelines for treatment, the chemotherapy regiment was not standardized across the institutions. Reasons for not starting adjuvant chemotherapy when indicated, interruption, and modification of drug regimen were collected to investigate compliance. RESULTS A total of 572 patients were included in the analysis. Two hundred and fifty-two (44.1%) patients received neo-adjuvant chemoradiation therapy. All patients underwent high anterior rectal resection, low anterior rectal resection, or Miles' procedure. Of 399 patients with an indication to adjuvant chemotherapy, 176 (44.1%) completed the treatment as planned. Compliance for patients who started chemotherapy was 56% (95% CI 50.4-61.6%). Sixty-six patients interrupted the treatment, 76 patients significantly reduced the drug dose, and 41 patients had to switch to other therapeutic regimens. CONCLUSIONS The present multicenter investigation reports a low compliance rate to adjuvant chemotherapy after rectal resection for cancer. Multidisciplinary teams should focus on future effort to improve compliance for these patients.
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Affiliation(s)
- Giulio M Mari
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Dario Maggioni
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Jacopo Crippa
- General Surgery Residency Program, University of Milan, Via Festa del Perdono, 7, 20100, Milan, Italy.
| | | | - Mauro A Scotti
- General Surgery Department, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Vittorio Giardini
- General Surgery Department, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Mattia Garancini
- General Surgery Department, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Eugenio Cocozza
- General Surgery Department, Varese Hospital, ASST Settelaghi, Varèse, Italy
| | - Giacomo Borroni
- General Surgery Department, Varese Hospital, ASST Settelaghi, Varèse, Italy
| | - Ilaria Benzoni
- Department of Surgery, Cremona Hospital, ASST Istituti Ospitalieri Cremona, Cremona, Italy
| | - Mario Martinotti
- Department of Surgery, Cremona Hospital, ASST Istituti Ospitalieri Cremona, Cremona, Italy
| | - Luigi Totaro
- Department of Surgery, Cremona Hospital, ASST Istituti Ospitalieri Cremona, Cremona, Italy
| | - Matteo Origi
- General Surgery Department, Niguarda Hospital, ASST Grande ospedale metropolitano Niguarda, Milan, Italy
| | - Michele Mazzola
- General Surgery Department, Niguarda Hospital, ASST Grande ospedale metropolitano Niguarda, Milan, Italy
| | - Giovanni Ferrari
- General Surgery Department, Niguarda Hospital, ASST Grande ospedale metropolitano Niguarda, Milan, Italy
| | - Pietro Achilli
- General Surgery Department, Niguarda Hospital, ASST Grande ospedale metropolitano Niguarda, Milan, Italy
| | | | - Antonio Martino
- General Surgery Department, AOU "SSMM della Misericordia", Udine, Italy
| | - Roberto Petri
- General Surgery Department, AOU "SSMM della Misericordia", Udine, Italy
| | - Francesca Botta
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | | | - Antonello Forgione
- General Surgery Department, Niguarda Hospital, ASST Grande ospedale metropolitano Niguarda, Milan, Italy
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Deidda S, Crippa J, Duchalais E, Kelley SR, Mathis KL, Dozois EJ, Larson DW. Hybrid minimally invasive/open approach versus total minimally invasive approach for rectal cancer resection: short- and long-term results. Int J Colorectal Dis 2019; 34:1251-1258. [PMID: 31139888 DOI: 10.1007/s00384-019-03311-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To reduce the technical challenges of a totally minimally invasive approach (TMA) and to decrease the morbidity associated with open surgery, a hybrid minimally invasive/open approach (HMOA) has been introduced as a surgical technique for rectal cancer. The aim of this study was to compare postoperative results and long-term oncologic outcomes between hybrid minimally invasive/open approach and totally minimally invasive approach in patients who underwent rectal resection for cancer. METHODS All patients with rectal cancer undergoing a totally minimally invasive approach or hybrid minimally invasive/open approach proctectomy between 2012 and 2016 were analyzed. Preoperative and postoperative outcomes were collected from a prospectively maintained institutional database. RESULTS Among 283 patients, 138 (48.8%) underwent a hybrid minimally invasive/open approach and 145 (51.2%) a totally minimally invasive approach. Preoperative characteristics were similar between groups except for distance from the anal verge, which was lower in totally minimally invasive approach group (50.7% vs 29%; p = 0.0008). Length of stay (LOS) was significantly longer in the hybrid minimally invasive/open approach group (6.4 vs 4.3; p = < 0.0001). The median follow-up was 29.6 (14-40.6) months. Overall survival and disease-free survival were not significantly different between groups. CONCLUSIONS Compared with a hybrid minimally invasive/open approach, a totally minimally invasive approach has a shorter length of stay and may improve short-term outcomes in patients undergoing proctectomy for cancer.
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Affiliation(s)
- Simona Deidda
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Emilie Duchalais
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Grass F, Lovely JK, Crippa J, Mathis KL, Hübner M, Larson DW. Early Acute Kidney Injury Within an Established Enhanced Recovery Pathway: Uncommon and Transitory. World J Surg 2019; 43:1207-1215. [PMID: 30684001 DOI: 10.1007/s00268-019-04923-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The present study aimed to assess the impact of perioperative fluid management on early acute kidney injury (AKI) rate and long-term sequelae in patients undergoing elective colorectal procedures within an enhanced recovery pathway (ERP). METHODS Retrospective analysis of consecutive patients from a prospectively maintained ERP database (2011-2015) is performed. Pre- and postoperative creatinine levels (within 24 h) were compared according to risk (preoperative creatinine rise ×1.5), injury (×2), failure (×3), loss of kidney function and end-stage kidney disease (RIFLE) criteria. Risk factors for early AKI were identified through logistic regression analysis, and long-term outcome in patients with AKI was assessed. RESULTS Out of 7103 patients, 4096 patients (58%) with pre- and postoperative creatinine levels were included. Of these, 104 patients (2.5%) presented postoperative AKI. AKI patients received higher amounts of POD 0 fluids (3.8 ± 2.4 vs. 3.2 ± 2 L, p = 0.01) and had increased postoperative weight gain at POD 2 (6 ± 4.9 vs. 3 ± 2.7 kg, p = 0.007). Independent risk factors for AKI were high ASA score (ASA ≥ 3: OR 1.7; 95% CI 1.1-2.5), prolonged operating time (>180 min: OR 1.9; 95% CI 1.3-2.9) and diabetes mellitus (OR 2.5; 95% CI 1.5-4), while minimally invasive surgery was a protective factor (OR 0.6; 95% CI 0.4-0.9). Five patients (0.1%) developed chronic kidney disease, and two of them needed dialysis after a mean follow-up of 33.7 ± 22.4 months. CONCLUSIONS Early AKI was very uncommon in the present cohort of colorectal surgery patients treated within an ERP, and long-term sequelae were exceptionally low.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, Bugnon 46, 1011, Lausanne, Switzerland
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Bugnon 46, 1011, Lausanne, Switzerland
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Crippa J, Mari GM, Miranda A, Costanzi AT, Maggioni D. Surgical Stress Response and Enhanced Recovery after Laparoscopic Surgery - A systematic review. Chirurgia (Bucur) 2019; 113:455-463. [PMID: 30183575 DOI: 10.21614/chirurgia.113.4.455] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2018] [Indexed: 11/23/2022]
Abstract
Background: Enhanced Recovery Program (ERP) is a multimodal perioperative protocol. Its feasibility and benefits on short term outcomes have been widely reported. These well described improvements, like shorter length of stay and early resumption of body's functions, represent the consequence of an attenuated surgical stress response (SSR). When this response is uncontrolled, it leads to postoperative complications and poor long-term outcomes. SSR can be easily monitored through the analyses of mediators in the bloodstream. Available evidences do not achieve to tell if ERP allows a measurable surgical stress reduction. In this review, we searched for papers investigating the surgical stress response and ERP applied to elective mini-invasive procedures, in order to better understand the level of evidence regarding the effectiveness of ERP in minimizing the surgical stress response. Materials and Methods: A systematic review of published literature was performed using PubMed, Cochrane, EMBASE and Google Scholar database, following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Included studies concerned SSR analysis in ERP patients undergoing laparoscopic surgery through different surgical specialties. Eight studies with a total of 632 patients were included. Results: The three steps of SSR, endocrine, inflammatory and nutritional were all reported in the papers included in this review. Results showed no powerful evidence of difference in endocrine phase while an attenuated inflammatory response was reported for ERP patients when Interleukin-6 (IL-6) and C Reactive Protein (CRP) were dosed. Nutritional status was also preserved as albumin, pre-albumin and transferrin had better values in these patients. Conclusions: ERP applied to different types of laparoscopic surgery has a role in reducing SSR. This can be shown by the analysis of mediators such as IL-6, CRP and nutritional markers.
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Mari GM, Crippa J, Borroni G, Cocozza E, Roscio F, Scandroglio I, Origi M, Ferrari G, Forgione A, Riggio V, Pugliese R, Costanzi ATM, Maggioni D. Symptomatic Uncomplicated Diverticular Disease and Incidence of Unexpected Abscess during Sigmoidectomy: A Multicenter Prospective Observational Study. Dig Surg 2019; 37:199-204. [PMID: 31117071 DOI: 10.1159/000500084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/31/2019] [Indexed: 12/10/2022]
Abstract
BACKGROUND Symptomatic uncomplicated diverticular disease can affect patients' everyday routine. Considerable efforts have been made to identify clinical features that correlate to the severity of the disease. Unexpected intraoperative abscesses are reported in large retrospective series, showing how uncomplicated symptoms and presentations can underlie a complicated disease. The aim of this study was to investigate the incidence of pericolic or intramural abscess in patients undergoing elective sigmoidectomy for symptomatic uncomplicated diverticular disease and see if chronic symptoms correlate to the presence of an abscess. METHODS Between January 2016 and June 2018, we prospectively collected data of patients who were given indication to elective sigmoidectomy for symptomatic uncomplicated diverticular disease. Patients were divided into 3 groups: acute resolving, smoldering, and atypical according to a previously described classification of uncomplicated diverticular disease. RESULTS One hundred fifty-eight consecutive patients were enrolled in the study. The median age was 63 years (22- 88), and the mean body mass index was 26 (±7) kg/m2. There were 114 patients in the acute resolving group, 36 in the smoldering group, and 8 in the atypical group. An unexpected abscess was reported in 75 patients (47.5%) during surgery or pathological examination. The incidence of -abscess was greater for patient in the smoldering group (p = 0.0243). CONCLUSION Our series of patients affected by symptomatic uncomplicated diverticular disease showed an incidence of unexpected pericolic or intramural abscess of 47.5%. Patients affected by smoldering diverticular disease presented a greater abscess rate.
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Affiliation(s)
- Giulio M Mari
- Department of Laparoscopic and Oncological General Surgery, ASST Monza, Desio Hospital, Desio, Italy
| | - Jacopo Crippa
- General Surgery Residency Program, University of Milan, Milan, Italy,
| | - Giacomo Borroni
- Surgical Oncology and Minimally Invasive Unit, ASST Settelaghi, Varese, Italy
| | - Eugenio Cocozza
- Surgical Oncology and Minimally Invasive Unit, ASST Settelaghi, Varese, Italy
| | - Francesco Roscio
- Division of General Surgery, ASST Sette Laghi, Galmarini Hospital, Tradate, Italy
| | - Ildo Scandroglio
- Division of General Surgery, ASST Valle Olona, Busto Arsizio General Hospital, Busto Arsizio, Italy
| | - Matteo Origi
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Ferrari
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonello Forgione
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Riggio
- Department of Laparoscopic and Oncological General Surgery, ASST Monza, Desio Hospital, Desio, Italy
| | | | - Andrea T M Costanzi
- Department of Laparoscopic and Oncological General Surgery, ASST Monza, Desio Hospital, Desio, Italy
| | - Dario Maggioni
- Department of Laparoscopic and Oncological General Surgery, ASST Monza, Desio Hospital, Desio, Italy
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Mari G, Costanzi A, Crippa J, Berardi V, Santurro L, Gerosa M, Maggioni D. Endoscopic Treatment of Anastomotic Bleeding in Laparoscopic Colorectal Surgery. Chirurgia (Bucur) 2019; 114:295-299. [PMID: 31060664 DOI: 10.21614/chirurgia.114.2.295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2019] [Indexed: 11/23/2022]
Abstract
Bleeding from the stapled line is a rare but potentially lethal complication that requires a proper and immediate management. Treatment for stapled anastomotic hemorrhage may be operative or conservative. We report three cases of anastomotic stapled line bleeding after colorectal surgery successfully treated endos-copically. Laparoscopic High Anterior Resection with a trans anal anastomosis according to Knight-Griffen with circular a stapler was performed for adenocarcinoma, rectal endometriosis and diverticular disease. All three patients had major rectal bleeding within 24 hours from surgery. 1 patients had endoscopy before the end of the surgical procedure. Endoscopic wash out with removal of the clots and infiltration of the bleeding sites along the stapled line with Adrenaline 1 : 10000 (2 ml) was performed achieving a good hemostasis. Early endoscopy is a safe and efficient treatment in colorectal anastomotic bleeding.
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Grass F, Lovely JK, Crippa J, Ansell J, Hübner M, Mathis KL, Larson DW. Comparison of recovery and outcome after left and right colectomy. Colorectal Dis 2019; 21:481-486. [PMID: 30585680 DOI: 10.1111/codi.14543] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 12/19/2018] [Indexed: 02/08/2023]
Abstract
AIM The present study aimed to compare functional recovery and surgical outcomes after left and right colectomies. METHOD Consecutive elective left and right colon resections for benign and malignant indications, performed between 2011 and 2016 and recorded in a prospectively maintained enhanced recovery database, were analysed. Demographic and surgical items, as well as functional recovery and 30-day complications, were compared between left-sided and right-sided colectomies. Multivariable analysis was performed to identify risk factors for postoperative ileus (POI). RESULTS In total, 1001 left and 1041 right colectomies were comparable regarding demographic factors; only body mass index (BMI) was higher in patients undergoing left-sided resections (> 30 kg/m2 : 33% vs 27%, P = 0.004). Malignancy (29% vs 67%, P < 0.001) and Crohn's disease (1% vs 31%, P < 0.001) were preponderant in right colectomies, whereas diverticular disease (68% vs 1%, P < 0.001) was the most common indication for left colectomy. Compliance with the enhanced recovery pathway (ERP) was comparable. While the minimally invasive approach was the preferred approach for both sides (61% vs 64%, P = 0.158), left colectomies took longer (180 ± 80 min vs 150 ± 70 min, P < 0.001), needed more perioperative fluids (3.1 ± 1.4 l vs 2.7 ± 1.5 l, P < 0.001) and resulted in greater postoperative weight gain (3.9 ± 6.5 kg vs 2.6 ± 6 kg, P = 0.025). Crohn's disease (OR = 2.64, 95% CI: 1.27-5.46) and fluid overload (OR = 2.02, 95% CI: 1.06-3.82) were independent risk factors for POI. CONCLUSION Despite equal ERP compliance, postoperative ileus was higher after right-sided colectomies. This finding was associated with Crohn's disease and fluid overload.
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Affiliation(s)
- F Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - J K Lovely
- Hospital Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - J Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - J Ansell
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - M Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Grass F, Crippa J, Mathis KL, Kelley SR, Larson DW. Feasibility and safety of robotic resection of complicated diverticular disease. Surg Endosc 2019; 33:4171-4176. [PMID: 30868321 DOI: 10.1007/s00464-019-06727-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/01/2019] [Indexed: 01/17/2023]
Abstract
This study aimed to assess intra- and postoperative outcomes of robotic resection of left-sided complicated diverticular disease. Retrospective analysis of a prospectively maintained institutional database on consecutive patients undergoing elective robotic resection for diverticular disease (2014-2018). All procedures were performed within an enhanced recovery pathway (ERP). Demographic, surgical and ERP-related items were compared between patients with simple and complicated diverticular disease according to intra-operative presentation. Postoperative complications and length of stay were compared between the two groups. Out of 150 patients, 78 (52%) presented with complicated and the remaining 72 (48%) with uncomplicated disease. Both groups were comparable regarding demographic baseline characteristics and overall ERP compliance. Surgery for complicated disease was longer (288 ± 96 vs. 258 ± 72 min, p = 0.04) and more contaminated (≥ class 3: 57.7 vs. 23.6%, p < 0.001) with a trend to higher conversion rates (10.3 vs. 2.8%, p = 0.1). While postoperative overall complications tended to occur more often after resections for complicated disease (28.2 vs. 15.3%, p = 0.075), major, surgical and medical complications did not differ between the two groups, and median length of stay was 3 days in both settings (p = 0.19). Robotic resection of diverticular disease was feasible and safe regardless of disease presentation by the time of surgery.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Quiram BJ, Crippa J, Grass F, Lovely JK, Behm KT, Colibaseanu DT, Merchea A, Kelley SR, Harmsen WS, Larson DW. Impact of enhanced recovery on oncological outcomes following minimally invasive surgery for rectal cancer. Br J Surg 2019; 106:922-929. [PMID: 30861099 DOI: 10.1002/bjs.11131] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/18/2018] [Accepted: 01/15/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oncological outcomes of locally advanced rectal cancer depend on the quality of surgical and oncological management. Enhanced recovery pathways (ERPs) have yet to be assessed for their oncological impact when used in combination with minimally invasive surgery. This study assessed outcomes with or without an ERP in patients with rectal cancer. METHODS This was a retrospective analysis of all consecutive adult patients who underwent elective minimally invasive surgery for primary rectal adenocarcinoma with curative intent between February 2005 and April 2018. Both laparoscopic and robotic procedures were included. Short-term morbidity and overall survival were compared between patients treated according to the institutional ERP and those who received conventional care. RESULTS A total of 600 patients underwent minimally invasive surgery, of whom 320 (53·3 per cent) were treated according to the ERP and 280 (46·7 per cent) received conventional care. ERP was associated with less overall morbidity (34·7 versus 54·3 per cent; P < 0·001). Patients in the ERP group had improved overall survival on univariable (91·4 versus 81·7 per cent at 5 years; hazard ratio (HR) 0·53, 95 per cent c.i. 0·28 to 0·99) but not multivariable (HR 0·78, 0·41 to 1·50) analysis. Multivariable analysis revealed age (HR 1·46, 1·17 to 1·82), male sex (HR 1·98, 1·05 to 3·70) and complications (HR 2·23, 1·30 to 3·83) as independent risk factors for compromised overall survival. Disease-free survival was comparable for patients who had ERP or conventional treatment (80·5 versus 84·6 per cent at 5 years respectively; P = 0·272). CONCLUSION Treatment within an ERP was associated with a lower morbidity risk that may have had a subtle impact on overall but not disease-specific survival.
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Affiliation(s)
- B J Quiram
- St Olaf College, Northfield, Minnesota, USA
| | - J Crippa
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - F Grass
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - J K Lovely
- Mayo Clinic Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - K T Behm
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D T Colibaseanu
- Mayo Clinic Pharmacy, Mayo Clinic, Rochester, Minnesota, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - A Merchea
- Mayo Clinic Pharmacy, Mayo Clinic, Rochester, Minnesota, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - S R Kelley
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - W S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - D W Larson
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Grass F, Hübner M, Lovely JK, Crippa J, Mathis KL, Larson DW. Ordering a Normal Diet at the End of Surgery-Justified or Overhasty? Nutrients 2018; 10:nu10111758. [PMID: 30441792 PMCID: PMC6266498 DOI: 10.3390/nu10111758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/10/2018] [Accepted: 11/11/2018] [Indexed: 12/14/2022] Open
Abstract
Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011–2016) were retrieved from a prospectively maintained institutional ERP database. The primary endpoint was postoperative ileus (POI). Surgical 30-day outcome and length of stay were compared between patients undergoing the pathway-intended early re-alimentation pattern and patients in whom early re-alimentation was not compliant. Out of the 7103 patients included, 1241 (17.4%) were not compliant with ERP re-alimentation. Patients with delayed re-alimentation presented with more postoperative complications (37 vs. 21%, p < 0.001) and a prolonged length of hospital stay (8 ± 7 vs. 5 ± 4 days, p < 0.001). While male gender (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.04–1.32), fluid overload (OR 1.38; 95% CI 1.16–1.65) and high American Society of Anaesthesiologists (ASA) score (OR 1.51; 95% CI 1.27–1.8) were independent risk factors for POI, laparoscopy (OR 0.51; 95% CI 0.38–0.68) and ERP compliant diet (OR 0.46; 95% CI 0.36–0.6) were both protective. Hence, this study provides further evidence of the beneficial effect of early oral feeding after colorectal surgery.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, 1011 Lausanne, Switzerland.
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Mari G, Crippa J, Costanzi A, Mazzola M, Magistro C, Ferrari G, Maggioni D. Genito-Urinary Function and Quality of Life after Elective Totally Laparoscopic Sigmoidectomy after at Least One Episode of Complicated Diverticular Disease According to Two Different Vascular Approaches: the IMA Low Ligation or the IMA Preservation. Chirurgia (Bucur) 2017; 112:136-142. [PMID: 28463672 DOI: 10.21614/chirurgia.112.2.136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2017] [Indexed: 11/23/2022]
Abstract
The arterial ligation during elective laparoscopic sigmoidectomy for diverticular disease can affect genito-urinary function injuring the superior hypogastric plexus, and can weaken the distal colonic stump arterial perfusion. Ligation of the inferior mesenteric artery distal to the left colic artery or the complete preservation of the inferior mesenteric artery can therefore be compared in terms of preservation of the descending sympathetic fibres running along the aorta to the rectum resulting in a different post operative genito urinary function. From January 2015 to March 2016, 66 patients underwent elective laparoscopic sigmoidectomy for diverticular disease among two enrolling hospitals. In one centre 35 patients underwent laparoscopic sigmoidectomy with the ligation of the inferior mesenteric artery distal to the left colic artery (low ligation). In the other centre 31 patient were operated on the same procedure with complete inferior mesenteric artery preservation (IMA preservation). There was no difference in terms of major complication occurred, first passage of stool and length of hospital stay between the two groups. Time of surgery was significantly shorter in LL group compared to IMA preserving group and intra operative blood loss was significantly lower in the LL group. There were no differences in the genito urinary function between the two group pre operatively, at 1 and 9 months post operatively. Genito urinary function did not significantly change across surgery in each groups. The low ligation and the IMA preserving vascular approach are safe end feasible techniques in elective laparoscopic sigmoidectomy for diverticular disease. They both prevent from genito-urinary post-operative disfunction and allow good post operative quality of life. The low ligation approach is related to shorter operative time and slower intra operative blood loss.
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Abstract
Peritoneal dialysis (PD) is an effective renal replacement therapy for the treatment of end-stage renal disease. Patients on PD undergoing abdominal open surgery often fail to resume PD. Laparoscopic surgery has recently become a serious alternative to open surgery in patients on PD to treat different abdominal pathologies. However, only a few studies have reported successful procedures without Tenckhoff catheter removal. The aim of this review is to describe how a laparoscopic technique can allow PD patients to deal with abdominal surgery without shifting to hemodialysis. Only 50 cases of laparoscopic surgical intervention in PD patients have been published to our knowledge. These case series largely concern laparoscopic cholecystectomies, appendectomies, nephrectomies, colectomies, and bariatric procedures. The reported cases show how laparoscopic surgery can be accepted as a valid option for several abdominal surgical procedures in patients on PD with good outcomes and early resumption of PD.
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Mari G, Costanzi A, Galfrascoli E, Rosato A, Crippa J, Maggioni D. Prospective Evaluation of Genito-Urinary Function after Laparoscopic Rectal Resection in the Elderly. Chirurgia (Bucur) 2016; 111:318-325. [PMID: 27604669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 06/06/2023]
Abstract
Laparoscopic anterior rectal resection with total mesorectal excision is related to sexual and urinary disorders. Anastomotic leak and neo-adjuvant radiation therapy are effective factors in worsening pelvic function. We report a series of 50 elderly (age 70) patients who underwent laparoscopic total mesorectal excision inquired about pre and post-operative genito-urinary function. Patients were interviewed preoperatively, 1 and 9 months post-operatively with validated questionnaires about sexual and urinary function and quality of life. They also underwent urofluximetric test with ultrasound measurement of the bladder remnant volume. The geriatric assessment was performed with the BARTHEL index. Urinary and sexual function slightly worsened after surgery although not significantly. Mean Gastrointestinal Quality of Life Indicator score decreased significantly from pre operative levels at 1 month from surgery. BARTHEL index did not change significantly across surgery. Maximum urinary flow, mean urinary flow, bladder residual volume worsened after surgery although not significantly. Laparoscopic anterior rectal resection with total mesorectal excision affects the genito-urinary status of elderly patients. Incidence of severe dysfunctions is similar to normal aged population.
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Mari G, Costanzi A, Crippa J, Falbo R, Miranda A, Rossi M, Berardi V, Maggioni D. Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol. Chirurgia (Bucur) 2016; 111:476-480. [DOI: 10.21614/chirurgia.111.6.476] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2016] [Indexed: 11/23/2022]
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