Giovanni Romano

Surgery has a key role for quality assurance of colorectal cancer screening programs: impact of the third level multidisciplinary team on lymph nodal staging

PurposeFrom 2011 to 2013 in the area of the Naples 3 public health district (ASL-NA3), a colorectal cancer screening program (CCSP) was developed. In order to stress the need of quality assurance procedures for surgery and pathology, a third level oncologic pathway was added and set up at a referral colorectal cancer center (RC). Lymph nodal (LN) harvesting, as a process indicator, and nodal positivity were adopted for an interim analysis.MethodsThe program was implemented by a series of audit meetings and a double type of multidisciplinary team (MDT): “horizontal” and “vertical.” Three hundred and forty colorectal cancer (CRC) patients underwent surgery: 119 chose to be operated at the RC (Gr In), 65 were operated at 22 district hospitals (DH) (Gr Out), and 156 symptomatic not screened patients were operated at the RC (Gr Sym).ResultsStatistical analysis revealed differences between Gr In and Gr Out colon groups both for LN harvesting (median of 26 and 11, respectively, Pu2009=u20090.0001), and for nodal positivity after the first screening round (34.78 and 19.45xa0%, respectively, Pu2009=u20090.0169). Results were all the more significant in a subset analysis on early T stage colon subgroups (In vs Out) both for LN harvesting (Pu2009<u20090.0001) and nodal positivity (Pu2009<u20090.0001).ConclusionxSignificant differences between RC and DHs were found, particularly for early-stage CRC patients. LN harvesting should be considered as a surrogate marker of quality assurance for at least screening hospitals for “minimum best” standard of care. This should lead to set up a third level in any CCSP.

Surgery for rectal prolapse: General criteria for the selection of the best treatment

Rectal prolapse is an intussusception of the rectum, which may be classified as mucosal, internal (occult) or complete (full thickness). Mucosal prolapse is a protrusion of the mucosa only without sliding of the muscular layer, which remains in place. Internal rectal prolapse does not come down beyond the anal canal and, frequently, is not associated with any symptoms; it is likely to be a precursor of a complete prolapse. Complete rectal prolapse is a full-thickness protrusion through the anal canal.

Total Anorectal Reconstruction with an Artificial Bowel Sphincter

BACKGROUND: The artificial bowel sphincter (Acticon ABS - American Medical Systems, Minneapolis, MN, USA) has been proposed as a treatment for patients with faecal incontinence. The good results achieved with this procedure encouraged us to utilize this device for reconstruction of patients who previously underwent an abdominoperineal resection (APR). METHOD: Between 1999 and 2000 we implanted the ABS in five patients undergoing an APR. One patient was male and four female, the mean age was 51.3 years. Three patients had been operated on for rectal cancer, one for rectal agenesia and one for a giant benign tumour of the pelvis. RESULTS: The length of follow up ranged from 6 to 22 months. Manometry assessed a basal pressure with the ABS cuff inflated between 58 and 62.2 mmHg. All but one achieved a good grade of continence with a Wexner score range between 3 and 9. A certain degree of impaired evacuation occurred in two patients but, with adequate training, this improved and did not affect patient satisfaction. CONCLUSION: The ABS is a good option for reconstruction of patients previously treated with an APR. As compared to electrostimulated graciloplasty the ABS technique seems to be easier to perform and more acceptable for the patients, although the cost of the device is still high.

Complete Mesocolic Excision With Central Vascular Ligation in Comparison With Conventional Surgery for Patients With Colon Cancer – The Experiences at Two Centers

Purpose Revolutions have occurred over the last 3 decades in the management of patients with colorectal cancer. Most advances were in rectal cancer surgery, especially after the introduction of the total mesorectal excision (TME) by Heald. However, no parallel advances regarding colon cancer surgeries have occurred. In 2009, Hohenberger introduced a new concept trying to translate the survival advantages of TME to patients with colon cancer. This relatively new concept of a complete mesocolic excision (CME) with central vascular ligation (CVL) in the management of patients with colon cancer represents an evolution in operative technique. We performed a comparative study between CME with CVL and conventional surgery for patients with colon cancer at Italian and Egyptian cancer centers, considering surgical quality and clinical outcome. Methods Seventy-nine Egyptian patients underwent conventional surgery (non-CME group) while 52 Italian patients underwent CME with sharp dissection between the embryological planes and CVL of the supplying vessels (CME group). Results Significantly better results were observed in terms of lymph node yield (CME group: 22.5 vs. non-CME group: 12; P < 0.0001) and lymph node ratio (CME group: 0.03 vs. non-CME group: 0.22; P < 0.0001). Regarding surgical morbidity, no significant difference was noted (CME group: 2 vs. non-CME group: 5; P < 0.702). Conclusion CME appears to be a safe procedure when performed by experienced hands through proper embryological planes. It also provides a superior specimen, with a higher lymph node yield, which consequently affects the lymph node ratio. Eventually, CME with CVL should be increasingly adopted and studied more deeply.

Modified Pull-through Technique With A Delayed High Coloanal Anastomosis: No Stoma and Scarless Surgery for Low Rectal Cancer

1113 DISEASES OF THE COLON & RECTUM VOLUME 60: 10 (2017) The Turnball–Cutait delayed coloanal anastomosis, also referred to as the pull-through procedure, was introduced for the treatment of selected patients with complex anorectal conditions that might otherwise require permanent stoma. Turnball–Cutait delayed coloanal anastomosis was progressively abandoned in favor of mechanical coloanal anastomoses but recently regained a role in the case of salvage surgery after anastomotic leak, hostile pelvis, or in the case of patient refusal for stoma.In this video we present a modified technique for delayed high coloanal anastomosis and its combination with a minimally invasive approach. A conventional low anterior resection, including high vascular ligation, complete splenic flexure mobilization, and total mesorectal excision, is carried out. Anal mucosectomy is then performed and the distal rectal stump pulled through the anus. Four referral stitches (which will be the markers for fashioning the delayed anastomosis) are placed between the viscera and the upper verge of the anal canal (cranially to the internal sphincter). In the second stage of the procedure (generally performed after 1 wk in spinal anesthesia) the adhesions between the colonic stump and the anal canal are bluntly dissected until the marker stitches. Some adhesions are intentionally left in place cranially to the anastomotic site to exclude the pelvis from contamination in case of leak. The colonic stump and the mesocolon lying on the posterior aspect are then sectioned at this level and the anastomosis completed with 4 additional stitches leaving the anal canal free from the residual colon. See Video at http://links.lww. com/DCR/A402.

Indications for Surgery and Surgical Techniques

At the present time, there are no uniform guidelines for treating locally recurrent rectal cancer (LRRC), and patients affected by local recurrence should be referred exclusively to tertiary centers where all expertise needed to provide patients with optimal treatment is available. In fact, there are a number of different options for treating LRRC that should be evaluated in a multidisciplinary team workup of individual cases. Recurrence location and extent, together with the evaluation of previously administered treatment, should be taken into account when determining the appropriate treatment strategy. Systemic chemotherapy, radiotherapy (RT), radiochemotherapy (RCT), and surgery — alone or in combination — can all play a role in achieving cure, long-term overall survival (OS), and palliation. In the vast majority of studies, 40–50% of patients with local recurrence are considered amenable to surgical exploration; 30–40% of them are reported to have had an R0 resection [1, 2]. This implies that just 20–30% of patients with recurrent rectal cancer will undergo a potentially curative resection, but these data are affected by selection criteria and surgical expertise at the different reporting institutions.

Erratum to: Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

Micaela Piccoli & Ferdinando Agresta & Vincenzo Trapani & Casimiro Nigro & Vito Pende & Fabio Cesare Campanile & Nereo Vettoretto & Enrico Belluco & Paolo Pietro Bianchi & Davide Cavaliere & Giuseppe Ferulano & Filippo La Torre & Marco Maria Lirici & Roberto Rea & Gianni Ricco & Elena Orsenigo & Simona Barlera & Emanuele Lettieri & Giovanni Maria Romano & on behalf of The Italian Surgical Societies Working Group

Artificial Bowel Sphincter

Fecal incontinence is a socially devastating problem. The treatment algorithm depends on the etiology of the disease. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). The best indications for the ABS are lesions of the anal sphincters that are inaccessible to local repair and not responsive to sacral nerve stimulation test or not indicated for such a test. A recent article that published experiences with the ABS showed that this technique had a high rate of morbidity, surgical reinterventions, and explants. Complications leading to explantation included perioperative infections, failure of wound healing, erosion of part of the device throughout the skin or the anal canal, late infection, and mechanical malfunction of the device due to cuff or balloon rupture. The ABS is suitable for well-motivated, selected patients with fecal incontinence of more than one year’s duration and whose condition is affected by an important personal, familial, and/or social disability.