Il 25 Maggio 2020 alle ore 14.00 BST (British Summer Time) si terrà il secondo webinar CovidSurg: Safe cancer surgery during the Covid-19 Pandemic.
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).
Sindrome dell’Intestino Irritabile
Dott. Roberto Perinotti
Rubrica diretta a quanti volessero porre dei quesiti al Presidente SICCR, Dott. Roberto Perinotti.