Aleix Martínez-Pérez

Pathologic Outcomes of Laparoscopic vs Open Mesorectal Excision for Rectal Cancer: A Systematic Review and Meta-analysis

Importance Rectal resection with mesorectal excision is the mainstay treatment for rectal cancer. Objective To review and analyze the evidence concerning the pathologic outcomes of laparoscopic (LRR) vs open (ORR) rectal resection for rectal cancer. Data Sources The Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, Scopus databases, and clinicaltrials.gov were searched for randomized clinical trials (RCTs) comparing LRR vs ORR. Study Selection Only RCTs published in English from January 1, 1995, to June 30, 2016, that compared LRR with ORR for histologically proven rectal cancer in adult patients and reported pathologic outcomes (eg, positive circumferential resection margin, and complete mesorectal excision) were eligible for inclusion. Of 369 records screened, 14 RCTs were selected for the qualitative and quantitative analyses. Data Extraction and Synthesis Two independent reviewers performed the study selection and quality assessment. Random-effects models were used to summarize the risk ratio (RR) and mean differences. Main Outcomes and Measures The rate of positive circumferential resection margin (CRM), defined as 1 mm or less from the closest tumor to the cut edge of the tissue, and the quality of mesorectal excision (complete, nearly complete, or incomplete). Results The meta-analysis included 14 unique RCTs with 4034 unique patients. Of 2989 patients undergoing rectal resection, a positive CRM was found in 135 (7.9%) of 1697 patients undergoing LRR and 79 (6.1%) of 1292 patients undergoing ORR (RR, 1.17; 95% CI, 0.89-1.53; P = .26; I2 = 0%) in 9 studies. A noncomplete (nearly complete and incomplete) mesorectal excision was reported in 179 (13.2%) of 1354 patients undergoing LRR and 104 (10.4%) of 998 patients undergoing ORR (RR, 1.31; 95% CI, 1.05-1.64; P = .02; I2 = 0%) in 5 studies. The distal resection margin involvement (RR, 1.12; 95% CI, 0.34-3.67; P = .86), the mean number of lymph nodes retrieved (mean difference, 0.05; 95% CI, −0.77 to 0.86; P = .91), the mean distance to the distal margin (mean difference, 0.01 cm; 95% CI, −0.12 to 0.15 cm; P = .87), and the mean distance to radial margins (mean difference, −0.67 mm; 95% CI, −2.16 to 0.83 mm; P = .38) were not significantly different between LRR and ORR. The risk for bias was assessed as low in 10 studies, high in 3, and unknown in 1. The overall quality of the evidence emerging from the literature was rated as high. Conclusions and Relevance Based on the available evidence, the risk for achieving a noncomplete mesorectal excision is significantly higher in patients undergoing LRR compared with ORR. These findings question the oncologic safety of laparoscopy for the treatment of rectal cancer. However, long-term results of the ongoing RCTs are awaited to assess whether these pathologic results have an effect on disease-free and overall patient survival.

IROA: International Register of Open Abdomen, preliminary results

BackgroundNo definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA).MethodsA prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers®) through a dedicated website: www.clinicalregisters.org.ResultsFour hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39±18.37; 56% male. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%),Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(±4.83) days; Mean number of dressing changes: 0.88(±0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p<0.0001) and with the fistula development (Pearson = 0.146 p= 0.016).Pediatric patients: 33 patients. Mean age: 5.91±(3.68) years; 60% male. Mortality: 3.4%; Complications: 44.8%; Fistula: 3.4%. Mean duration of OA: 3.22(±3.09) days.ConclusionTemporary abdominal closure is reliable and safe. The different techniques account for different results according to the different indications. In peritonitis commercial negative pressure temporary closure seems to improve results. In trauma skin-closure and Bogotà-bag seem to improve results.Trial registrationClinicalTrials.gov NCT02382770

Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA)

INTRODUCTION No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. MATERIAL AND METHODS A prospective analysis of adult patients enrolled in the IROA. RESULTS Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. CONCLUSION Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Laparoscopic management of gastric perforation secondary to mesenteroaxial volvulus in a patient with laparoscopic adjustable gastric banding: LSG for acute gastric volvulus

A 54‐year‐old woman was admitted to the emergency department with a 2‐week history of alimentary vomiting. She had undergone laparoscopic adjustable gastric banding 6 years earlier. CT revealed a mesenteroaxial gastric volvulus and ischemia on the gastric wall. Emergent diagnostic laparoscopy was performed, and severe peritonitis and gastric necrosis caused by volvulation was found. After band removal, a fundal perforation was noted, but a viable lesser curvature enabled laparoscopic sleeve gastrectomy to be performed. The postoperative course was uneventful. Laparoscopic adjustable gastric banding is considered a safe and effective method for the surgical treatment of obesity, but it is associated with a number of complications, such as pouch dilatation and band slippage. Although infrequent, ischemic complications are life‐threatening conditions that require urgent surgery. This is the first report of this unusual complication managed laparoscopically.

Erratum to: IROA: International Register of Open Abdomen, preliminary results

[This corrects the article DOI: 10.1186/s13017-017-0123-8.].

Mirizzi syndrome: a new insight provided by a novel classification

Backgrounds/Aims Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease. Methods A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes. Results 28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none. Conclusions Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula.

Commentary on "Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision", published in BMC Cancer 2016 Jul 4;16(1):380. doi:10.1186/s12885-016-2428-5.

The first meta-analysis comparing laparoscopic (laTME) and transanal total mesorectal excision (taTME) for rectal cancer ‘‘Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision’’ appeared recently in BMC Cancer [1]. After a careful reading, we felt that some critical aspects of this study deserve further comment. First, we read in the beginning of the introduction: ‘‘Recently published randomized clinical trials (RCTs), such as COLOR II, COREAN and CLASICC, have shown better results for laTME, in terms of short-term and long-term outcomes, when compared with open TME’’. This sentence is inaccurate, even untrue. Focusing on the short-term results, the COLOR II trial showed statistically significant differences in favor of laparoscopy only in blood loss, bowel recovery and length of hospital stay, with no differences in postoperative morbidity and mortality between the two approaches. The COREAN study had similar results, also showing less postoperative pain and better physical and intestinal recovery after laparoscopy. The CLASSIC study, the earliest of these three, had negative results in the laparoscopic anterior resection group. Concerning the longterm outcomes, all these trials came to the same conclusions: there were no differences between laTME and open TME. In addition, the authors of this meta-analysis did not take into account the results of the two most recent RCTs, in which the laparoscopic approach failed to achieve the non-inferiority criteria for pathological outcomes of surgical resection in comparison to the open approach [2, 3]. Thus, the statement that laTME is associated with better shortand longterm outcomes than open TME is a matter of debate. Second, to perform the meta-analysis, the authors selected seven articles that in their opinion compared laTME and taTME. Nevertheless, two of these studies did not make such a comparison, since the group matched with laTME was in reality a transanal-transabdominal approach in which the perianal dissection is performed with conventional instruments (not using dedicated transanal surgical platforms) [4, 5]. Moreover, in these studies the perineal dissection only involved the distal rectum [4], or the first 5 cm of caudal dissection [5], and the rest of mesorectal dissection was performed by a conventional abdominal laparoscopic approach. The authors tried to avoid this problem by naming these techniques ‘‘partial-TME’’ and performing a subgroup analysis without the latest two studies. In this subgroup analysis, which evaluated 16 different variables, only three reached statistical significance in favor of taTME, such as shorter operative time (which can almost be considered inherent to taTME, as a two-field dissection can be performed simultaneously), lesser overall complications (which might be biased due to the heterogeneous definitions of this variable between the studies; moreover, no complication considered alone reached statistical significance between the two approaches), and better circumferential resection margins. Remarkably, in this latter comparison, the mean difference was dramatically shifted by the weight (94 %) provided by the extremely narrow standard deviation of the study published by Ferndandez-Hevia et al. [6]. & A. Martı́nez-Pérez aleix.martinez.perez@gmail.com