Left Colon Resection Research Articles

INDOCYANINE GREEN IN LEFT SIDE COLORECTAL SURGERY SEGMENTAL RESECTION TO DECREASE ANASTOMOTIC LEAK: A PARALLEL RETROSPECTIVE COHORT STUDY OF 115 PATIENTS

BackgroundWe investigated the impact of Indocyanine Green (ICG) angiography on reducing anastomotic leakage (AL) after elective left segmental colon resection, including transverse resection. While ICG is widely used in colorectal surgery to assess vascularization, its true effect on AL, particularly in left segmental resections, remains unclear. Study DesignThis retrospective, monocentric cohort study included patients undergoing left and transverse colon resection from January 2017 to July 2023. Patients were divided into ICG and no-ICG groups. The primary outcome was AL, with secondary outcomes including postoperative morbidity and length of stay. ResultsOf the 115 patients enrolled, 53 received ICG and 63 did not. AL occurred in 6 patients in the no-ICG group, but none in the ICG group. No significant correlation was found between ICG use and other confounding factors. Postoperative length of stay was also shorter in the ICG group. ConclusionsThe use of ICG was associated with a reduction in AL, with no cases in the ICG group. These findings suggest a potential benefit of ICG, warranting confirmation in future large-scale studies. Clinical trial registrationclinicaltrial.gov (NCT05981937)

FP4.10 - Oncosurgical Outcome Differences of Left and Right Colonic Cancer Resections Still a Colorectal Enigma

Abstract Aims The study aimed to compare surgical outcomes between right (RCC) and left colonic cancer (LCC) resections at a single centre (DGH) with special reference to 3 and 5-year survival rates. Methods 100 colonic resections (2017-2021) were included. Length of stay (LOS), pathology results and 3 and 5-year survival rates were analysed. The Kaplan-Meier estimate was used for patients within 5 years post-operative. Results 68 RCC and 32 LCC noted. RCC: 37 female, 31 male, median age of 73. 66 R0 resections, 2 R1, none R2. TNM: 52 (86.1%) had T3/4, 26 (38.2%) had N1/2. 20 had extramural venous invasion (EMVI), 26 intramural venous invasion (IMVI), 8 mucinous, 11 perineural invasion. Estimated 3-year survival rate 0.8530, 5-year 0.7766. No local recurrences, 4 subsequent distant metastases within 5 years. LCC: 11 female, 21 male, median age of 67. 23 R0, 2 R1, 2 R2 resections. TNM: 28 (87.5%) had T3/4, 15 (46.9%) had N1/2. 18 EMVI, 11 IMVI, 1 mucinous, 9 perineural invasion. Estimated 3-year survival rate 0.7498, 5-year 0.5965. No local recurrences, 9 subsequent distant metastases within 5 years. Both cohorts’ median LOS similar (6 days). Discussion This study shows higher survival rates in RCC, contradicting acclaimed superiority of LCC survival in literature(1-5). The limited LCCs in this study (during Covid pandemic) being pathologically more advanced, possibly accounts for the statistically significant mortality. A prospective audit of tumour biology and oncological outcome is ongoing with intentions to validate our early observation.

Anastomotic Leakage after Colorectal Surgery is Associated with a Specific Tissue-Microbiome Signature

Abstract Background Anastomotic leakage (AL) occurs in 5-15% of colorectal resections. In addition to well-known risk factors, recent evidence suggests that the gut microbiota might critically affect anastomotic healing. However, studies in humans are limited. Aims To explore differences in pre-operative microbiome of patients with or without AL and identify anastomosis-protective or damaging bacterial species. Methods Clinical records of patients undergoing left colon or rectal resection with anastomosis at our department between 2013 and 2021 were screened. AL cases were matched equally to controls by propensity score, based on common AL risk factors. The microbiome was analyzed by amplification and sequencing of the V4 region of the 16S gene of DNA extracted from formalin-fixed paraffin-embedded mucosa taken at the proximal and distal margin of the resected specimen, mixed in equal amounts. Differential abundance of identified operational taxonomic units (OTUs) in AL-cases and controls was tested by using the R-package DESeq2. Results Among 588 patients screened, 41 cases and 42 matched controls were eligible for microbiome analysis. Patient characteristics were similar except for a higher percentage of rectal resections in the AL group. Out of 5406 OTUs identified, 197 OTUs were differentially abundant between the two groups (adjusted-p value <0.05). Of those, 175 OTUs were more prevalent in the AL-group, in particular Fusobacterium periodonticum (32% vs. 5% of patients) and bacteria from the Hyphomicrobium genera (39-44% vs. 12-21%); 22 were more prevalent in the control group, in particular Akkermansia muciniphila (26 vs. 17%) and Eubacterium sireum (19 vs. 5% of patients). Conclusion Our analysis unravels AL-associated microbiome-signatures and identifies bacterial species highly prevalent in particular in patients with AL. These findings could be used for future research to develop targeted antibiotic therapy that helps prevent AL.

Cadaveric Study of Colon-Lengthening Maneuvers After Sigmoidectomy.

Creation of a tension-free colorectal anastomosis after left colon resection or low anterior resection is a key requirement for technical success. The relative contribution of each of a series of known lengthening maneuvers remains incompletely characterized. The aim of this study was to compare technical procedures for lengthening of the left colon before rectal anastomosis. A series of lengthening maneuvers was performed on 15 fresh cadavers. Mean distance gained was measured for each successive maneuver, including 1) high inferior mesenteric artery ligation, 2) splenic flexure takedown, and 3) high inferior mesenteric vein ligation by the ligament of Treitz. Cadaveric study. The premobilization and postmobilization position of the proximal colonic end was measured relative to the inferior edge of the sacral promontory. Measurements of the colonic length relative to the sacral promontory were taken after each mobilization maneuver. The inferior mesenteric artery, sigmoid colon, and rectum specimen lengths were measured. The distance from the inferior border of the sacral promontory to the pelvic floor was measured along the sacral curvature. Mean sigmoid colon resection length was 34.7 ± 11.1 cm. Before any lengthening, baseline reach was -1.3 ± 4.2 cm from the sacral promontory. Inferior mesenteric artery ligation yielded an additional 11.5 ± 4.7 cm. Subsequent splenic flexure takedown added an additional 12.8 ± 9.6 cm. Finally, inferior mesenteric vein ligation added an additional 11.33 ± 6.9 cm, bringing the total colonic length to 35.7 ± 14.7 cm. BMI and weight negatively correlated with length gained. The study was limited by nature of being a cadaver study. Stepwise lengthening maneuvers allow significant additional reach to allow a tension-free left colon to rectal anastomosis. See Video Abstract . ANTECEDENTES:La creación de una anastomosis colorrectal libre de tensión tras una resección de colon izquierdo o tras una resección anterior baja es un requisito clave para el éxito relacionado con la técnica quirúrgica. La relativa contribución de las diversas maniobras de alargamiento permanece caracterizada de manera incompleta.OBJETIVO:El propósito de este estudio fue la de comparar procedimientos técnicos de alargamiento del colon izquierdo previo a la anastomosis rectal.DISEÑO:Una serie de maniobras de alargamiento fueron realizados en 15 cadáveres frescos. La distancia promedio ganada fue medida para cada maniobra sucesiva, incluyendo (1) ligadura alta de la arteria mesentérica inferior, (2) descenso del ángulo esplénico, (3) ligadura alta de la vena mesentérica interior mediante el ligamento de Treitz.AJUSTES:Estudio cadavérico.PRINCIPALES MEDIDAS DE RESULTADO:La posición premobilizacion y postmobilizacion del extremo proximal del colon fue medido tomando en cuenta el borde inferior del promontorio sacro. Las mediciones de la longitud colónica en relación al sacro fueron tomadas luego de cada maniobra de movilización. Fueron tomadas así mismo las longitudes de la arteria mesentérica inferior, el colon sigmoides y recto. Las distancias desde el borde inferior del promontorio sacro al suelo pelvico fueron medidas a lo largo de la curvatura sacra.RESULTADOS:Average sigmoid colon resection length was 34.7 ± 11.1 cm. Prior to any lengthening, baseline reach was -1.3 ± 4.2 cm from the sacral promontory. Inferior mesenteric artery ligation yielded an additional 11.5 ± 4.7 cm. Subsequent splenic flexure takedown added an additional 12.8 ± 9.6 cm. Finally, inferior mesenteric vein ligation added an additional 11.33 ± 6.9 cm, bringing the total colonic length to 35.7 ± 14.7 cm. BMI and weight negatively correlated with length gained.LIMITACIONES:Este estudio tuvo como limitación la naturaleza de haber sido un estudio cadavérico.CONCLUSIONES:Maniobras de alargamiento permiten un alcance adicional significativo permitiendo de esta manera una anastomosis de colon izquierdo a recto libre de anastomosis. (Traducción-Dr Osvaldo Gauto ).

Renal Actinomycosis Camouflaging as Malignancy: A Diagnostic Challenge

Actinomycosis is an unusual infection that typically appears in the thoracic, cervicofacial, and abdominal areas. However, the occurrence of renal actinomycosis in adults remains rare, with few cases reported since 1990. Actinomycosis is often considered “the most misdiagnosed disease” due to its tendency to be overlooked even by experienced clinicians. Hereby authors report a case of a 55-year-old male with pyrexia of unknown origin and weight loss, presenting with pallor upon general examination. Further investigation revealed microcytic hypochromic anaemia and neutrophilic leukocytosis on peripheral blood smear. A heterogeneous mass with internal vascularity in the left kidney was identified on abdominal ultrasound. Subsequent Computed Tomography (CT) abdomen confirmed an ill-defined lesion in the mid and lower pole of the left kidney, with extrarenal extension into the perinephric space, and a filling defect in the left renal vein. A provisional diagnosis of a left renal tumour infiltrating the spleen and splenic flexure of the colon was made. The patient then underwent a left radical nephrectomy, splenectomy, and limited colonic resection. Histopathological examination confirmed actinomycosis with abscess formation in the kidney and colon. The patient was treated with crystalline penicillin for eight weeks until considered disease-free. Renal actinomycosis poses challenges in diagnosis due to its ambiguous clinical and laboratory features. Often mimicking malignant neoplasms on imaging, it can confuse even experienced clinicians. Early detection is crucial for precise medical intervention and to reduce unnecessary surgeries.

Cost Analysis of Outpatient Colectomy in a Tertiary Center: A Projected Medico-Economic Evaluation

Aim of the study: Short stay processes are incentives to unburden chronically stressed healthcare systems. The aim of this study is to analyze financial implications of day admission (DAS) and outpatient strategies for colon resections in a prospective payment system (PPS) using Diagnosis Related Group (DRG) coding. Methods: Consecutive patients undergoing left and right colonic resections between January 1, 2019 and December 31, 2020 were included. Medico-economic evaluations of the virtual outpatient and day admission surgery groups based on predefined criteria were compared to the identical group of patients who underwent surgery in the actual traditional inpatient setting. In a second step, postoperative complications of the virtual outpatient group were assessed. Cost-revenue analysis was performed using a micro-costing approach including direct medical costs. Results: Overall (N = 257), 97 (37.7%) colectomies would have been potentially eligible for an outpatient strategy. The global costs of the actual inpatient strategy totaled USD 3 634 392 with a global revenue of USD 3 571 069, corresponding to a cost coverage rate of 98%. The result of the virtual DAS strategy would have been a net loss of USD 15 800 (coverage rate of 99%) due to 4 low length of stay outliers triggering a reimbursement reduction and preventing a positive net result of USD 16 208. The pilot reference outpatient case’s revenue and cost amounted to respectively USD 7479 and USD 6911 (cost coverage of 108%). Conclusion: From both any given hospital and healthcare system point of view, elective outpatient colectomy for selected patients is the most cost-saving option. However, in a prospective payment system implemented to avoid bad incentives, the latter can unintentionally disadvantage best performing hospitals and impede widespread adoption of high-value strategies.

Fate of de-functioning ileostomy after left colon and rectal cancer resection: observation from a single unit of a cancer hospital.

Background: De-functioning ileostomy (DS) has been shown to reduce rate of anastomotic leak after left colon and rectal cancer resection and can avoid consequences of leak with its morbidity and possible mortality. Externalisation of bowel is not easily appreciated; patients always inquire about the timing of closure and not all stomas are closed. The aim of the study is to assess the timing of stoma closure and the reasons for stoma becoming permanent. Methods: Patients who underwent surgery for left colon and rectal cancer with de-functioning stoma from April 2019 to May 2022 in single unit of Bhaktapur Cancer Hospital, were assessed regarding timing of stoma closure. We have made a policy of stoma closure after completion of adjuvant therapy. De-functioning stoma that was not reversed at follow up were assessed regarding reason for it becoming permanent. Results: Forty-two patients underwent de-functioning stoma during the study period; 30 after rectal resection, 2 after pouch creation, 6 after anterior resection and 4 after left hemicolectomy. Twenty-eight (77%) stomas were closed, 5 are receiving adjuvant treatment. Closure was not done in 8 patients; 5 due to recurrence of disease; 1 due to patient wish, 2 deaths occurred prior to closure, one due to COVID-19 and another due to acute myocardial infraction. One patient with multiorgan resection died within 30 days of surgery due to other medical cause. The median time of stoma closure after completion of adjuvant treatment is 8 weeks, IQR (7-10). Patients had to stay with stoma for a median period of 6months, IQR (5-8). The median time for discharge after stoma reversal is 9 days, IQR (7-10). There were 4 Grade II Clavien-Dindo complications after stoma closure. Conclusion: Seventy- seven percent of patients with DS underwent closure in our series. Recurrence was the most common cause for it becoming permanent.

INTRA-ABDOMINAL MULTI-ORGANS INFARCTION IN 73-YEARS OLD FEMALE PATIENT WITH HYPERTENSIVE CRISIS: A CASE REPORT AND REVIEW OF LITERATURE

Objective: Unexpected clinical course Background: In hypertensive crisis patients, intestinal ischemia has been reported, while gastric ischemia is rare due to its multiple blood supply. A hypertensive crisis is classified according to the progression of end-organ failure, which includes cerebral, cardiac, and renal insults. Case Presentation: A 73-year-old female patient with uncontrolled hypertension and diabetes mellitus presented with dyspnea and fatigue. Her blood pressure was 248/157 mmHg and her serum blood glucose was 301 mg/dl. In the emergency room, she received antihypertensive treatment and was admitted to the intensive care unit to be monitored. 48 hours later, she developed nausea, vomiting, constipation and severe abdominal pain. A CT scan of the abdomen revealed infarction patches in the left renal and the spleen while the first colonoscopy was irrelevant. The second colonoscopy revealed left colonic and sigmoid necrosis. Finally, she underwent exploratory laparotomy that identified ischemic necrosis of the greater curvature of the stomach, multiple levels of the small intestine, sigmoid and descending colon. Partial gastrectomy, left colonic resection, sigmoidectomy, and colostomy were done. Conclusion: This case illustrates the unusual site of ischemia in an uncontrolled hypertensive patient, as well as the difficulty of managing the patient and the adverse outcome. In order to rule out intra-abdominal organ involvement, any patient who develops abdominal pain in the course of hypertensive emergency should be evaluated for surgical consultation and contrast-enhanced CT.

Spontaneous Bilateral Lumbar Region Colocutaneous Fistulae. A Case Report

Bilateral spontaneous lumbar colocutaneous fistulae are rare. They are associated with high costs of care, morbidity, and mortality. We present the case of a 50- year-old male patient who presented with a 10-year history of two low-output spontaneous colocutaneous fistulae from both the left and right lower lumbar regions with no identifiable risk factors. He was managed operatively with segmental left colon resection and a temporary loop ileostomy with uneventful recovery after reversal of the ileostomy 2 months later. Whether the etiology of the fistulae is clinically apparent or not, the management should follow commonly known principles. This report highlights a case of bilateral lumbar region spontaneous colocutaneous fistulae of unknown cause that was managed operatively with satisfactory short-term outcomes.

Laparoscopic resections in colorectal cancers-short term and medium-term outcome with 2 years follow up

Background: After decades of debate and controversy, the short-term benefits and at least equivalent long-term outcomes of laparoscopic colon surgery compared to open surgery has now been well established. Methods: In this article, short- and medium -term outcomes of patients undergoing laparoscopic colorectal surgery for cancer in a tertiary care hospital is analysed. A retrospective analysis of prospectively collected data of all patients who had laparoscopic management of colorectal cancer (CRC) for 3 years was done. Patients were followed up for 2 years after treatment. The prospectively collected data was analysed to find out the incidence of complications, local or distant metastases and the survival rates. Results: There were 65 patients who underwent laparoscopic surgery among 120 patients who had treatment for colorectal carcinoma in the study period. The 26 patients underwent low anterior resection followed by 14 patients and 13 patients undergoing left colonic and right colonic resections respectively. While abdominoperineal resection was carried out in 6 patients, 3 each patients were treated by ultra-low anterior resection and subtotal colectomy. Morbidities of varying grade according to Clavien Dindo classification was less for laparoscopic surgery. Recurrence occurred in 14.8% at 2 years follow up. The 2-year survival rate was noted to be 87.7% among the study group who underwent laparoscopic surgery. Conclusions: Judicious selection of patients and the appropriate selection of technique help to achieve good short-and long-term results without compromising on oncological outcome in laparoscopic surgeries for colorectal malignancies.

Elective robotic partial colon and rectal resections: series of 170 consecutive robot procedures involving the Da Vinci Xi robot by a community general surgeon.

Robotic colorectal procedures may overcome the disadvantages of laparoscopic surgery. While the literature has multiple studies from specialized centers, experience from general surgeons is minimal. The purpose of this case series is to review elective partial colon and rectal resections by a general surgeon. 170 consecutive elective partial colon and rectal resections were reviewed. The cases were analyzed by type of procedure and total cases. The outcomes analyzed were procedure time, conversion rate, length of stay, complications, anastomotic leak, and node retrieval in the cancer cases. There were 71 right colon resections, 13 left colon resections, 44 sigmoid colon resection sand 42 low anterior resections performed. The mean length of procedure was 149min. The conversion rate was 2.4%. The mean length of stay was 3.5days. The percentage of cases one or more complications was 8.2%. There were 3 anastomotic leaks out of 159 anastomoses (1.9%). The mean lymph node retrieval was 28.4 for the 96 cancer cases. Robot partial colon and rectal resections on the Da Vinci Xi robot can be completed safely and efficiently by a community general surgeon. Prospective studies are needed to demonstrate reproducibility by community surgeons performing robot colon resections.

Primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in left colonic and rectal cancer resections — the first Russian experience

Primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in left colonic and rectal cancer resections — the first Russian experience

The Extraperitoneal Approach to Left-Sided Colorectal Rectal Resections: EXPERTS Procedure.

Current transperitoneal approaches to colorectal resections can be technically challenging, especially in obese patients. The head-down position can lead to rare but serious complications, e.g. compartment syndrome and brachial plexus injuries. The aim of this study was to assess the safety and feasibility of a novel extraperitoneal approach in patients requiring anterior resection. The extraperitoneal left-sided approach was performed in the supine position. A 5cm LIF incision was created into which a Gelpoint port was inserted. The full video of the procedure is embedded in the QR code below. The procedure was performed by three surgeons with experience in minimally invasive surgery. Patients requiring left colonic resections were prospectively selected over a 2-year period. Forty-one patients were prospectively assessed between March 2020 and April 2022; 26 were males, with a median age of 67 (55-88)years. The average body mass index (BMI) was 30 (22-40). 38/41 cases were cancers and three were diverticular diseases; 31 cases had anterior resection and 11 had sigmoid colectomies. Peak airway pressures were significantly less (10 cmH20) in the supine position compared with the head-down position (p<0.0001). Median time to identify the ureter and gonadal vessels was 23 (3-55)min, and median time to return of bowel function and length of stay was 2 (0-13) and 5 (IQR 3-7) days, respectively. No intraoperative complications or postoperative mortality occurred within 90 days of discharge. Three patients had anastomotic complications, and an R0 resection was achieved in all 38 cancer patients. The median lymph node count was 16. Extraperitoneal surgery for left colonic resections is safe and clinically feasible, and allows for early identification of important retroperitoneal structures.

Selective approach to arterial ligation in radical sigmoid colon cancer surgery with D3 lymph node dissection: A multicenter comparative study.

Radical surgery for sigmoid colon cancer is commonly performed with complete mesocolic excision (CME) and apical lymph node dissection, reached by central vascular ligation (CVL) of the inferior mesenteric artery (IMA) and associated extended left colon resection. However, IMA branches can be ligated selectively according to tumor location with D3 lymph node dissection (LND), economic segmental colon resection and tumorspecific mesocolon excision (TSME) if IMA is skeletonized. This study aimed to compare left hemicolectomy with CME and CVL and segmental colon resection with selective vascular ligation (SVL) and D3 LND. Patients (n= 217) treated with D3 LND for adenocarcinoma of the sigmoid colon between January 2013 and January 2020 were included in the study. The approach to vessel ligation, colon resection and mesocolon excision was based on tumor location in the study group, while in the comparison group, left hemicolectomy with routine CVL was performed. Survival rates were estimated as the primary endpoints of the study. Long- and short-term surgery-related outcomes were evaluated as the secondary endpoints of the study. The studied approach to the IMA branch ligation was associated with a statistically significant decrease in intraoperative complication rates (2 vs 4, p= 0.024), operative procedure length (225.56 ± 80.356 vs 330.69 ± 175.488, p <0.001), and severe postoperative morbidity (6.2% vs 19.1%, p= 0.017). Meanwhile, the number of examined lymph nodes significantly increased (35.67 vs 26.69 per specimen, p <0.001). There were no statistically significant differences in survival rates. Selective IMA branch ligation and TSME resulted in better intraoperative and postoperative outcomes with no difference in survival rates.

Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection.

Restoration of bowel continuity after left extended colectomy may be challenging because the remaining colon may not reach the rectal stump without tension to perform a safe anastomosis. Performing a total colectomy with ileorectal anastomosis (IRA) is an option, but the quality of life can be significantly impaired due to loose stools and an increase in bowel frequency. In contrast, the preservation of the right colon and ileocaecal valve in the Deloyers procedure (DP) might ensure a better stool consistency and bowel transit, and therefore a superior quality of life. A transverse study comparing patients that underwent DP versus patients with an IRA was performed. Postoperative morbidity, mortality, functional outcomes, and quality of life were analysed between groups. Quality of life after the surgical procedure was assessed with the SF-36 V2® health survey. A total of 16 patients with DP and 32 with IRA were included. The groups had similar demographic characteristics concerning age, sex, body mass index, ASA classification, diagnosis and Charlson comorbidity index. The median follow-up was 55 months for DP and 99 months for IRA. Postoperative complications were similar in both groups. Patients in the DP group had fewer bowel movements (P=0.01), tenesmus (P=0.04) and use of loperamide (P=0.03). DP patients achieved better scores in physical pain (P=0.02) and general health (P < 0.01) than IRA patients. DP for intestinal continuity restoration after extended left colon resection is a safe and feasible alternative, possibly achieving better functional outcomes and quality-of-life compared to IRA.

SP9.1.5 Occult appendix pathology in patients undergoing colorectal cancer resection suggests a role for appendectomy at left colon or rectal cancer resection

Abstract Aims There is epidemiological evidence suggesting that the incidence of appendicular neoplasms is increasing. The purpose of this study is to assess the incidence of appendix neoplasms in patients undergoing colorectal cancer resection in a unit where standard of care is appendectomy, with consent, when left colon or rectal cancer resection is performed. Methods This is a retrospective single-centre study on a prospectively collected data base of 718 consecutive patients undergoing colorectal cancer resection between January 2015 and June 2021. The primary outcome was the proportion of histologically abnormal appendix specimens at incidental appendectomy. Secondary outcome was complications from incidental appendectomy. Results Overall, 222/718(31%) patients had previous appendectomy. The remaining 496 comprised 169/496 (34%) who had a right-/extended-right hemicolectomy or sub-total colectomy which incorporates appendectomy, and 327/496(66%) who had left-sided resection (left-hemicolectomy, anterior resection or abdomino-perineal excision) with incidental appendectomy. At definitive histology, 454(92%) had a normal appendix, 13(2.6%) had inflammatory appendix pathology, 17(3.4%) had a hyperplastic/serrated polyp and 12(2.4%) had an appendix neoplasm, which included 5 carcinoids and 7 low-grade appendiceal mucinous neoplasms (LAMN). In the 327 patients who had incidental appendectomy, 7(2.1%) had a neoplasm (4 carcinoid and 3 LAMN). There were no complications attributable to appendectomy. Conclusion Patients undergoing left sided colorectal cancer surgery with an appendix in situ should be counselled on the benefits of co-incidental appendectomy to treat the small proportion with synchronous neoplasms and inflammation and eradicate the risk of metachronous appendicitis or a subsequent appendix tumour.

Audit of laparoscopic surgery for colon cancer in Morocco: A report of the results of a prospective multicentre cohort study

BackgroundLittle data is available about colon laparoscopic surgery in low mid-income countries. The aim of this study was to audit the status and results of laparoscopic colon cancer surgery in Morocco. Patients and methodsThis was a prospective study performed at 4 academic departments in Morocco between January 1, 2018, and March 31, 2020. All adult patients who underwent elective right or left colonic resection for colon adenocarcinoma were included. The main outcomes were the rate of laparoscopic surgery (LS) and the comparison of its short-term outcomes with open surgery (OS). ResultsAmong 121 patients included, 52 (43%) underwent laparoscopic resection (0–49.3%). Five surgeons (29%) performed at least one laparoscopic resection. There were more left colectomies in the laparoscopic group (71.2% vs. 39.1%. p = 0.0004), and more extended resections (23.1% vs. 40.6%. p = 0.043) and T4 stage (19% vs. 37.5%. p = 0.037) in the open group. There were no differences in 90-days overall and serious complications. OS patients had significantly more harvested lymph nodes (14 vs. 18. P = 0.007) and higher median surgical margins (6 cm vs. 9 cm. P = 0.003) than LS patients. ConclusionsLS for colon cancer in Morocco is performed by few surgeons, who apply strict patient selection for laparoscopic cases. It was associated with lower quality resections compared to open surgery. There are still many challenges requiring more focus on training, certification, centralization and standardisation of care across the nation.

Predictors of Clinical Outcomes Following Laparoscopic Colectomy for Traumatic Injury.

Laparoscopic colectomy following traumatic injury has been increasingly utilized, but open resection remains the standard of care. Therefore, identifying appropriate candidates for laparoscopy is critically important. This study's purpose was to identify predictors of clinical outcomes in patients undergoing laparoscopic colectomy following traumatic injury. The National Trauma Databank was queried for patients undergoing laparoscopic colectomy within 48 hours of admission between 2007 and 2015. Patient, injury, and management characteristics were abstracted. Multivariable regression analyses adjusted for baseline characteristics and identified significant predictors of clinical outcomes. A total of 581 patients satisfied inclusion criteria. The median age was 31years, 465 (80%) were male, and 321 (55%) sustained penetrating injuries. An ostomy was created in 143 (25%) cases. Multivariable logistic regression showed that significant predictors of mortality included a falling mechanism (odds ratio [OR] 104.917, P = .002), admission tachycardia (OR 5.823, P = .001), admission hypotension (OR 26.089, P < .001), and multi-system injuries like head (OR 1.587, P = .008) and thoracic (OR 1.627, P = .001) injuries. Significant predictors of unplanned reoperation included transverse (OR 7.657, P = .033) and left (OR 17.155, P = .014) colon resections, obesity (OR 24.407, P = .016), and chronic respiratory disease (OR 32.963, P = .018). Ostomy creation was significantly associated with neither mortality nor unplanned reoperation. These data suggest that readily identifiable preoperative characteristics are significantly associated with differences in clinical outcomes. Additional research is required to determine if varying treatment based on these qualities can improve outcomes.

Robotic left-stapled total intracorporeal bowel anastomosis versus stapled partial extracorporeal anastomosis: operative technical description and outcomes

BackgroundAlthough there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution’s techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA).MethodsPatients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure.ResultsFrom a review of our institution’s data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA.ConclusionsOur series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.

The impact of assistants' reverse alignment surgical skill proficiency on laparoscopic colorectal surgery.

We aimed to investigate the difference in the surgical outcome based on whether the assistant overcame the mirror image in laparoscopic colorectal surgery. Three hundred patients who underwent laparoscopic colorectal surgery performed by single operator were divided into 2 groups. Based on the assistants' experience, patients who underwent surgery involving 1 of 6 residents with an experience of fewer than 30 surgeries each were classified into group 1. Patients who underwent surgery involving a single fellow as an assistant with an experience of over 1,000 surgeries were classified into group 2. According to the type of surgery, patients were divided into left and right colon resection groups and the surgical outcome of groups 1 and 2 was investigated. Group 2 exhibited shorter operation time, less bleeding, shorter postoperative hospital stay, lower open conversion, and anastomotic leakage rate than group 1. In right colon resection, the operation time was shorter in group 2. In left colon resection, group 2 exhibited shorter operation time, less bleeding, shorter postoperative hospital stay, and lower anastomotic leakage rate. In the multivariate analysis, the assistant was a factor affecting the operation time in the entire surgery. Assistants' reverse alignment surgical skill proficiency was a factor affecting the operation time.