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Surgical risk’s stratification remains one of the great challenges for the surgeon, especially in oncological patients. For this purpose, it appears fundamental to consider, side by side with the traditional prognostic factors related to the oncological disease and patient’s comorbidity, the nutritionals factors as well. It seems mandatory to evaluate and possibly to treat any nutritional derangement before surgery.
Several studies, such as the studi of Dolan et al. (Tech Proctol 2019), show that sarcopenia in colo-rectal cancer patients a is associated with worse surgical outcomes, poor survival and bad tollerance to chemotherapy.
Although potentially modifiable, as oppposed to pathological staging, there are few reported interventions to modify muscle mass and potentially improve patient outcomes in the surgical setting.
Bozzetti et al. (Ann Oncol 2017), states that sarcopenia is also involved in a vicious circle made of mutual negative interactions between sarcopenia itself and chemotherapy. Indeed, there is a wide agreement showing that sarcopenic patients show a decreased response to chemotherapy because they are often forced to reduce chemotherapy dosage (or to delay the cycles of administration) due to increased toxicity. Probably this happens because it is a common habit to dose chemotherapy only as function of the body surface area, without considering that fat mass, in sarcopenic patients, can accounts for a larger and unpredictable part of body weight.
The University of Michigan created the “Michigan Surgical Home and Optimization Program” to help those patients actively prepare for surgery. Using a technique called “Morphomic Analysis” patients are engaged in a customized intervention program.
Thus, this “training” program aims patients to understand their high-risk condition and to engage them in a pre-habilitation schedule based on the improvement of four strictly-dependent areas: increasing physical activity, improving the respiratory function – for example by quitting smoke habits, gaining a better alimentation and reducing psycho-physical stress trough special exercises. (Englesbe MJ. et al. Surgery. 2017)
Moug S.J et al, in a randomized control trial , titled “Does prehabilitation modify muscle mass in patients with rectal cancer undergoing neoadjuvant therapy? A subanalysis from the REx randomised controlled trial“ show the results obtained by the two groups (ie those entrusted to pre-rehabilitation and those without) of rectal cancer patients undergoing neoadjuvant chemotherapy (NACRT)
Prehabilitation improved muscle mass in patients with rectal cancer who had NACRT
This is the first study which reports modification of muscle mass with prehabilitation in patients with colorectal cancer who have undergone neoadjuvant therapy. The graduated individualised walking programme provided sufficient muscle overload to increase psoas muscle mass in 65% of the intervention group in comparison to the controls, where 67% had the expected reduction in muscle mass as a consequence of having long-course chemoradiotherapy. With 14% of patients presenting with sarcopenia at diagnosis, prehabilitation may have a further role to play in the perioperative pathway.
Certainly, large-scale randomized clinical trials are required; however, it seems appropriate to underline that to treat a modifiable risk factor by means of rebalancing programs could offer a survival benefit in cancer patients, especially if they need chemotherapy.
Dr. Beatrice Pessia e Dr. Lucia Romano
Dipartimento di Chirurgia
Università degli studi dell Aquila
From the embryological point of view the colonic splenic flexure is a watershed between the right (foregut) and the left (hindgut) colon, resulting in its dual vascular supply and lymphatic drainage towards both superior and inferior mesenteric territories. Furthermore, several studies found that blood ﬂow in the distal transverse colon and splenic flexure exhibits a highly variable anatomy. Grifﬁth ﬁrst reported that in most of the cases the blood supply to the splenic ﬂexure is carried through the left colic artery and only in 11% of cases it is provided by the left branches of the middle colic artery. Subsequently, others reported that the middle colic artery is completely absent in 20% of cases, a ‘true’ middle colic artery could be found in only 46% of specimens and an accessory middle colic artery running towards the splenic ﬂexure can be identiﬁed in about one third of patients, branching from the superior mesenteric artery in the majority of cases (Grifﬁth JD Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl 1956; 51: 241–56. Sakorafas GHG et al Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol 2006; 15: 243–55. Mike M et al Reappraisal of the vascular anatomy of the colon and the consequences for the deﬁnition of surgical resection. Dig Surg 2013; 30: 383–92). By means of laparoscopic scintigraphic mapping, lymphatic drainage in physiologic status was detected preferentially directed towards the left colic pedicle with 9:1 ratio whilst in patients with colon cancer conflicting results were reported (Vasey CE et al Lymphatic drainage of the splenic ﬂexure deﬁned by intraoperative scintigraphic mapping. Dis Colon Rect 2018; 61: 441–6). The majority of lymph node metastases were located along the paracolic arcade and the left colic artery in the series of Nakagoe, De Angelis failed to ﬁnd metastatic nodes along the superior mesenteric territory whilst Watanabe using peritumoural injection of indocyanine green detected ﬂuorescence along the accessory middle colic artery towards its origin when this branch was present (Nakagoe T et al Carcinoma of the splenic ﬂexure: multivariate analysis of predictive factors for clinicopathological characteristics and outcome after surgery. J Gastroenterol 2000; 35: 528–35. De Angelis N et al Laparoscopic extended right hemicolectomy versus laparoscopic left colectomy for carcinoma of the splenic ﬂexure: a matched case–control study. Int J Colorectal Dis 2016; 31: 623–30. Watanabe J et al Evaluation of lymph ﬂow patterns in splenic ﬂexural colon cancers using laparoscopic real-time indocyanine green ﬂuorescence. Int J Colorectal Dis 2017; 32: 201–7). As standardized oncological resections are established according to the lympho-vascular anatomy, the optimal surgical treatment of splenic flexure cancer remains still debatable and both extended right hemicolectomy and left colonic resection have been proposed. Till now, pertinent literature fails to show any significant difference between the two procedures with regards to long-term oncological outcome.
In the last issue of Techniques in Coloproctology (volume 24, issue 8, August 2020) Yamaoka and coworkers report a mono-institutional retrospective study of a series of 538 patients submitted to curative resection for stage I-III cancer of the proximal transverse-splenic flexure-distal descending colon with the aim of investigating the distribution of lymphatic metastases. The paper shows a comprehensive and very detailed lymph node mapping pointing out the frequency of the metastatic involvement of every station. The subgroup of patients with splenic flexure cancer exhibited a significantly lower proportion of lymph node metastases in the intermediate and main region than proximal transverse or distal descending subgroups, as in more than 90% of pathological stage III patients metastatic nodes were found within the pericolic region. Furthermore, in the splenic flexure subgroup, no patient had node metastases neither at left colic level nor inferior mesenteric root. The analysis of the horizontal tumoral spreading demonstrated that in splenic flexure cancer it was mainly directed toward the oral than the anal side of the tumor with an incidence of pericolic metastases of 42.6% vs 16.7% respectively. Unfortunately, as no patients in this group underwent division of the root of the middle colic artery no data are available concerning the nodes’ involvement at that level.
The secondary end-point of the study is the long-term outcomes (disease-specific survival rate): no significant differences were found among the groups but no firm conclusion can be drawn due to the retrospective design of the study, the different proportion of D3 resections and the lack of a control arm.
Dipartimento di Chirurgia – Ospedale di Sanremo
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).