Sono state pubblicate su Colorectal Disease le Linee Guida sul management della malattia diverticolare colica della European Society of Coloproctology.
The July issue of Techniques in Coloproctology includes two papers about laser treatment of fistula-in-ano: an editorial by Giamundo (Laser treatment for anal fistulas: what are the pitfalls?) and an original article by de Bonnechose et al. (Laser ablation of fistula tract (LAFT) and complex fistula-in-ano: “the ideal indication” is becoming clearer…).
The main indication of the technique is the treatment of high or complex anal fistulas, where other surgical procedures may impair the continence.
Since in Literature there is a great variability in the results of this technique – in particular Giamundo reports a healing rate of 71,1% [Giamundo et al. Colorect Dis 2014], while de Bonnechose of 44,6% – the aim of the Authors is to investigate the predictive factors of success or failure of laser treatment for fistula-in-ano.
There may be several explanations for the different success rates of the studies previoulsy published in the Literature.
The patients are not exactly comparable between studies: the main biases are the great variability in type, length and size of the fistulas, the size of the internal orifice and the proportion of inter-sphincteric, trans-sphincteric or supra-sphincteric tract.
Moreover, the shrinkage of fistula tracts caused by laser energy is linked to the following features:
- fistula tract length
- fistula diameter (less effective over 4-5 mm)
- internal orifice size
that are difficult to estimate.
The Authors agree on the need of fistula tract preparation as a bridge-to-surgery with abscesses drainage, fistula curettage and placement of a loose seton, that may induce the formation of fibrotic tissue and fistula caliber.
Since LAFT is a blind procedure, another critical point is the evaluation of the amount of the necessary energy for the shrinkage, in terms of total amount of energy administered and of amount of energy delivered per centimeter of fistula. The last is difficult to be measured but Giamundo believes that is more significative than the total amount of energy administered during the procedure.
De Bonnechose identifies two fistulas categories based on the total amount of energy administered:
- fistulas requiring less than 400 J
- fistulas requiring more than 400 J
Fistulas requiring less than 400 J had a significantly higher healing rate (65%) compared to fistulas requiring more than 400 J (32%): this could be explained by larger diameter fistulas that require more energy to be closed or by the “overburning” effect of too much energy. De Bonnechose identifies a trend in favor of lower energy/cm, but without reaching statistical significance.
Another questionable point is the treatment of the internal orifice: in the study by Bonnechose the internal orifice was not closed, but in patients with wide internal orifice (larger than the probe) the heling rate was lower (15.4%). Since that both the Author suggest the closure of a wide internal orifice with an advancement flap.
Finally, when we consider as end point the recurrence rate, real recurrence must be differentiated from non-healing or persistent fistula.
In conclusion all the Authors confirmed that the fistula-in-ano laser treatment is an effective sphincter-saving technique and the success rate should be compared with the other complex anal fistulas sphincter sparing techniques (fibrin glue, plugs).
At the same time, this comparison is complex since the huge variability of the considered characteristics.
SOS Coloproctologia e disfunzioni del pavimento pelvico
Laparoscopic right hemicolectomy (LRHC) is a common performed procedure and is considered by many to be a standard of care in the treatment of benign and malignant diseases of the right colon, allowing faster recovery with analogous oncological results when compared with open procedure [van Oostendorp et al. Surg Endosc. 2017].
Extracorporeal (EC) and intracorporeal (IC) anastomosis have been described for ileocolic anastomosis: to perform EC anastomosis a greater mobilization of the colon inside the body, mesenteric tractions and exteriorization of the bowel through midline periumbilical incision are needed. On the other hand, IC anastomosis does not require bowel exteriorization and the resected segment of the colon can be delivered through a midline vertical incision or a Pfannenstiel incision; however, it is technically demanding and requires advances laparoscopic skills [Ricci C et al. Langenbecks Arch Surg. 2017].
Several observational studies assessed the safety and efficacy of IC versus EC anastomosis with discordant results. However, recent meta-analyses, reported reduced postoperative infectious and overall complications in the postoperative course in favour of the IC anastomosis technique. [Aiolfi A et al. J Laparoendosc ADV. 2020].
These results are limited by the quality of the analysed studies, in term of study design, sample size, lack of standardised surgical technique and postoperative management, and heterogeneity in definition of outcomes. Therefore, to date there are no guidelines on the indications for performing each type of anastomosis, and the selections of IC versus EC anastomosis depends on the personal expertise and preference of the surgeon [Emile S H et al. Tech Coloproctol. 2019].
A recent single-centre, double-blinded, randomized controlled study compared outcomes between IC and EC techniques in 140 patients (70 in each group). Intraoperative results recorded a non-significant IC anastomosis superiority over EC anastomosis, while postoperative results showed IC anastomosis to be better in recovery of bowel function (2 vs 3 days for median time to first flatus and 4 vs 4.5 days median time to first stool; p=0.003 and p=0.032 respectively) and postoperative pain (particularly on postoperative day 3; p=0.002), with similar overall 30-day morbidity rates and severity of complications in the two groups. However, the IC anastomotic leak rate was higher than the EC one (8.6% vs 2.9%), although this finding was not statistically significant [Allaix M E et al. Ann Surg. 2019].
In this volume (Volume 24, Issue 6, June 2020) of Techniques in Coloproctology, Bou Saleh N. and his colleagues reported the results of their retrospective, non-randomized, multicentric study, with the aim to compare the short-term post-operative results obtained in patients undergoing LRHC in tertiary centres using either IC or EC anastomosis.
Postoperative morbidity, including medical and surgical complications and postoperative outcomes, and mortality were analysed during the hospital stay or within 90 days after surgery in 597 patients undergoing LRHC. The indications for surgery were neoplasm in 451 cases (75.54%), polyps in 93 cases (15.58%) and inflammatory bowel disease in 53 cases (8.88%). An IC anastomosis was performed in 150 patients (25.13%) and an EC anastomosis in 447 patients (74.87%). The patients in the two groups were comparable except for BMI (higher in the IC group; p=0.003) and gender (there were more males in IC group; p=0.005). The results showed a shorter duration of the surgical procedure in IC group (150 vs 195 min; p>0.001); the incidence of medical complications (cardiac, vascular and pulmonary) was significantly higher in EC group (p=0.049) and was confirmed at the multivariate analysis. A shorter hospital stay was observed in the IC group (median of 7 versus 8 days; p=0.003), with no differences in terms of surgical outcomes and 90-day mortality.
Even if this multicentre study collected a great number of patients in tertiary centres involving experts in both anastomotic technique and the patients were collected in a relative short period of time (2005-2015) in which there have not been technical changes, prospective randomised trials with objective classification of postoperative complications “a priori” established are needed to confirm the postoperative advantages of IC anastomosis pointed out in the present study.
To date LRHC is considered the standard of care for benign and malignant diseases of the right colon, allowing a more rapid postoperative recovery and a lower rate of surgical wound infection with the same effective oncological radicality and most laparoscopic side-to-side ileocolic anastomoses are performed extracorporeally, due to technical difficulties. Available data do not allow to state that IC is superior to EC anastomosis. Several ongoing randomized studies are registered on https://clinicaltrials.gov and evidence from these studies will hopefully bring to definitive results.
ASST Fatebenefratelli Sacco, Università degli Studi di Milano
Hartmann’s reversal (HR) is a complex surgical procedure with significant postoperative morbidity, which is designed to reduce the physical and psychological problems associated with a permanent colostomy. Minimally invasive techniques have become popular in colorectal surgery, but HR can be considered one of the most technically demanding procedures in these terms [Horesh N, et al. Tech Coloproctol. 2018].
In fact, the first Hartmann’s procedure is often performed in a “hostile” abdomen, with peritonitis, bowel ischemia or infection, and this causes adhesions and difficulty in recognizing anatomical structures. The surgical field may also be sometimes affected by radiotherapy and chemotherapy, and all these factors contribute to increase the difficulty in restoring bowel continuity [Celentano V, et al. J Laparoendosc Adv Surg Tech A. 2018].
Nevertheless, laparoscopic approach reduced morbidity compared with the conventional open procedure; laparoscopy has been associated with faster recovery and better outcomes when compared with open surgery [Toro A, et al. Gastroenterol Res Pract, 2014; Celentano V, et al. Int J Colorectal Dis, 2015].
In this volume (Volume 24, Issue 5, May 2020) of Techniques in Coloproctology, D’Alessandro A. and his colleagues reported the results of their retrospective, case-controlled study, with the aim to compare single-port laparoscopic Hartmann’s reversal (SP-HR) and the standard multi-port laparoscopic approach (MP-HR).
The idea of the single port laparoscopic variant was to augment the advantages of the standard laparoscopic surgery. In particular, with the SP-HR it is possible to reduce the number of abdominal accesses, with consequent reduction of the risk of surgical site infection, pain, abdominal wall hemorrhage, and possibly bowel adhesions.
Comparing two groups of patients (Group A: SP-HR; Group B: MP-HR), they found that conversion to open surgery did not occur in any patient in either group; mean operative time and median length of hospital stay was shorter in Group A than in Group B; the overall morbidity rate was lower in Group A than in Group B (11.4% vs 18.2%). They concluded that the SP-HR technique was safe, efficient and totally comparable to MP-HR.
Despite the limitations related to the low sample size and to the lack of long-term follow-up, the results obtained encourage the realization of further research in the field of single-incision laparoscopic surgery.
Eradicating sepsis and promote healing represent the end-point of anal fistula treatment, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional open surgery seems to be relatively safe and well accepted in clinical practice.
However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter with subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced for minimising the injury to the anal sphincters and preserving optimal function.
(Limura E et al. World J Gastroenterol. 2015)
Numerous surgical procedures have been introduced for the treatment of complex fistula in anus, including ligation of intersphincteric fistula tract (LIFT), anal advancement flaps, injection of fibrin glue, collagen paste or autologous adipose tissue, fistula plug, video-assisted anal fistula treatment (VAAFT) and fistula laser closure (FiLaC™). (Adegbola SO et al. Tech Coloproctol. 2017.)
Fistula-tract Laser Closure (FiLaC™), a new and promising sphincter-preserving treatment, might be a valuable treatment option in these patients, but the date literature are variable. (De Hous N et al. Tech Coloproctol. 2019.)
In the volume 24, issue 4 (April 2020) of Tech Coloproctol, Elfeki H. et al. in a systematic review , evaluate the outcomes in terms of healing and complications, to determine the efficacy and safety of FiLaC™. In total, 454 patients were reviewed where 67.4% were males. Regarding the clinical type of fistulae, the majority were transphincteric (69.16% of cases), intersphincteric in 20.93%, supra/extrasphincteric in 8.37%, only superficial in 7 (1.54%) patients. One hundred and fifty-nine (35.02%) patients had recurrent fistula after previous surgical treatment.
The systematic analysis showed that the rate of primary healing among the studies was 67.3%, with a recurrences rate of 32.7%. It should be noted that the percentage of primary healing does not differ significantly from that of most other techniques and therefore it is confirmed that we do not yet have a “gold standard”.
Rate of complications was 4%: all of them were minor complications and the weighted mean rate of continence affection was 1% in the form of minor soiling. It is noteworthy that most of the failures after FiLaC™ were in the form of non-healing of the fistula rather than recurrence, representing only 3%. The failure rate could be attributed to several factors, however in literature there is no shared definition of persistence / recurrence both in terms of chronological interval and dignity modalities: in this sense the overall data of “failure” could be more objective than a subdivision that could reflect the heterogeneity of the studies. Undetected secondary tracts and various calibres of the fistula lumen are key factors which may hinder the sealing effect of laser fiber. These promising results should place FiLaC™ in the surgical armamentarium for anal fistula treatment.
Future randomized trials should be done to compare efficacy and safety by comparing multiple sphincter preserving techniques.
Beatrice Pessia M.D.
Lucia Romano M.D.
Dipartimento di chirurgia
Università degli Studi dell’Aquila
We open a new section of our website with the aim to focus the attention on a paper chosen by the Editorial committee from the coloproctological literature. An article with a short comment will be reported monthly. We start this column right in the middle of the Covid19 outbreak, a dramatic event which is causing an untried burden for health systems. This will certainly stimulate a deep rethinking of political and social priorities, lifestyles and health management and strategies. This pandemic has been called a “war” and probably is the first one in the modern era during which surgery is “in quarantine” while microbiologists, pulmonologists and infectious disease specialists are at the forefront. However, in the near future when the surgical activity will resume regularly it will have to deal with a new economic and financial scenario.
Robotic rectal surgery is a procedure whose cost-effectiveness ratio is still an open question under investigation. Robotic surgery offers advantages on conventional laparosopy including dexterity and ambidextrous capability, lack of tremors and motion scaling potentially overcoming the anatomical difficulties of rectal resection in lower rectal cancer expecially in obese/male patients. The ROLARR trial found that robotic-assisted laparoscopic surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy when performed by surgeons with varying experience in robotic surgery. Corrigan N et al. (Trials 2018; Jun 27;19(1):339) suggested that the learning effects could lead to biased comparison between treatments as surgeons participating to the trial were much more experienced in conventional laparoscopic than in robotic surgery. A subsequent systematic review of 1 RCT and 27 comparative studies (Jones K et al. World J Gastrointest Oncol 2018; Nov 15;10(11):449-464) failed to demonstrate any superiority of robotic over laparoscopic TME for many surgical outcomes except early passage of flatus, lower risk of conversion and shorter hospitalization.
In the volume 24, issue 3 (March 2020) of Tech Coloproctol, Quijano Y et al published an observational prospective mono-institutional study comparing robotic vs laparoscopic surgery for rectal cancer, with the aim to evaluate their cost-effectiveness. This comprehensive analysis estimated mean cost and QUALYs per patients based on the total direct hospital care costs, with the exception of the acquisition and maintanance of the robotic device. Through this model, the Authors foudn that overall mean costs are similar betweeen the two approaches demonstrating that robotic resection is a cost-effective procedure. They suggest further investigations to detect in which groups of patients it can be more advantageous under this aspect. On the other hand, narrowing the indications seems to be in contradiction with the aforementioned learning effects as the learning curve has been estimated completed after 40 robotic rectal resections (Ielpo B et al. Int J Colorectal Dis 2017; 32:1423–1429).