Mauro Verra

Experimental assessment of a novel robotically-driven endoscopic capsule compared to traditional colonoscopy

BACKGROUND Despite colonoscopy represents the conventional diagnostic tool for colorectal pathology, its undeniable discomfort reduces compliance to screening programmes. AIMS To evaluate feasibility and accuracy of a novel robotically-driven magnetic capsule for colonoscopy as compared to the traditional technique. METHODS Eleven experts and eleven trainees performed complete colonoscopy by robotic magnetic capsule and by conventional colonoscope in a phantom ex vivo model (artificially clean swine bowel). Feasibility, overall accuracy to detect installed pins, procedure elapsed time and intuitiveness were measured for both techniques in both operator groups. RESULTS Complete colonoscopy was feasible in all cases with both techniques. Overall 544/672 pins (80.9%) were detected by experimental capsule procedure, while 591/689 pins (85.8%) were detected within conventional colonoscopy procedure (P=ns), thus establishing non-inferiority. With the experimental capsule procedure, experts detected 74.2% of pins vs. 87.6% detected by trainees (P<0.0001). Overall time to complete colon inspection by robotic capsule was significantly higher than by conventional colonoscopy (556±188s vs. 194±158s, respectively; P=0.0001). CONCLUSION With the limitations represented by an ex vivo setting (artificially clean swine bowel and the absence of peristalsis), colonoscopy by this novel robotically-driven capsule resulted feasible and showed adequate accuracy compared to conventional colonoscopy.

Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks

BACKGROUND Anastomotic leaks are a severe complication after colorectal surgery. We aimed to evaluate the long-term efficacy of endoscopic vacuum therapy for their treatment. METHODS Retrospective review of a series of post-surgical colorectal leaks treated with endoscopic vacuum therapy, with minimum follow-up of 1 year. Generalized peritonitis or haemodynamic instability was considered contraindication to endoscopic treatment. RESULTS Endoscopic vacuum therapy was applied in 14 patients with colorectal leak, in 2 cases complicated by recto-vaginal fistula. Overall success rate was 79%, favoured by early beginning of treatment (90%) and presence of a stoma (100%) and no preoperative radiotherapy (86%). Median duration of treatment was 12.5 sessions (range 4-40). Median time for complete healing was 40.5 days (range 8-114), for a median cost of treatment of 3125 Euros. No complication related to endoscopic vacuum therapy was observed. Further surgery was required in 3 cases. CONCLUSION Endoscopic vacuum therapy is a safe treatment for post-surgical leaks, with high success rates.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) and colorectal cancer

Surgical techniques and technologies are rapidly evolving. In the field of colorectal surgery the transanal video‐assisted approach was introduced by Buess, 30 years ago, with transanal endoscopic microsurgery (TEM). In more recent years different techniques and technologies have been proposed, including natural orifice specimen extraction (NOSE), natural orifice transluminal endoscopic surgery (NOTES) and single‐access surgery. Furthermore, a better understanding of the prognostic and risk factors of rectal cancer has allowed TEM to expand its indications to local resection of selected tumours, and more recently there have been proposals for sentinel node biopsy in colon and rectal cancer.

Laparoscopy for extraperitoneal rectal cancer reduces short-term morbidity: Results of a systematic review and meta-analysis

Background The role of laparoscopy in the treatment of extraperitoneal rectal cancer is still controversial. The aim of the study was to evaluate differences in safety of laparoscopic rectal resection for extraperitoneal cancer, compared with open surgery. Materials and methods A systematic review from 2000 to July 2012 was performed searching the MEDLINE and EMBASE databases (PROSPERO registration number CRD42012002406). We included randomized and prospective controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary endpoints were 30-day mortality and morbidity. Then a meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model. Relative risk (RR) was used as an indicator of treatment effect. Results Eleven studies, representing 1684 patients, met the inclusion criteria: four were randomized for a total of 814 patients. Mortality was observed in 1.2% of patients in the laparoscopic group and in 2.3% of patients in the open group, with an RR of 0.56 (95% CI 0.19–1.64, p = 0.287). The overall incidence of short-term complications was lower in the laparoscopic group (31.5%) compared to the open group (38.2%), with an RR of 0.83 (95% CI 0.73–0.94, p = 0.004). Surgical complications, wound complications, blood loss and the need for blood transfusion, time for bowel movement recovery, food intake recovery, and hospital stay were significantly lower or less frequent in the laparoscopic group. The incidence of intra-operative injuries, anastomotic leakages, and surgical re-interventions was similar in the two groups. Only operative time was in favour of the open group. Conclusions Based on the evidence of both randomized and prospective controlled series, mortality was lower after laparoscopy although not significantly so, while the short-term morbidity RR, including subgroup analysis, was significantly lower after laparoscopy for extraperitoneal rectal cancer compared to open surgery.

Control user interfaces for a robotic-aid platform for endo and laparoscopic applications: which is the best?

2nd Biennial Meeting of the Eurasian Colorectal Technologies Association (ECTA) Turin, Italy, 15–17 June 2011 ECTA President: F. Seow-Choen Congress President: M. Morino Podium Presentations COLORECTAL CANCER TREATMENT PREVENTION AND TREATMENT OF ANASTOMOTIC LEAK IN MIDDLE AND LOW RECTAL SURGERY D. De Giorgi, O. Poti, G. Marcucci, P. Mingolla, M. Gambato, G. Borgia, M. Sciuto, C. Marra Department of Surgery, Copertino Asl Lecce, Copertino (Lecce), Italy Background In the middle and low rectal surgery, the most difficult complication is anastomotic dehiscence. In our department, we designed an intraoperative technique to position a perianastomotic drain through the levator ani muscle thus preventing fecal fistulas and anastomotic leaks, without a proximal diverting stoma. In laparoscopic operations, we added a transparietal loop, suspending the terminal ileum, a technique known as ghost ileostomy. Methods Since 1994, we have performed 289 operations with sphincter-preserving total mesorectal excision for rectal carcinoma (lesions in the lower one-third of the rectum) without a diverting stoma. Patients with anastomotic leak without sepsis were treated with enteral nutrition for 25 days. After this time, if the leak persisted, we constructed a diverting stoma. In all cases, we placed a drain through the levator ani muscle by lifting the muscle of anus. Since 2007, we performed 31 laparoscopic resections for rectal cancer and in all cases we used a ghost ileostomy and a drain inserted through the levator ani muscle. Results There were 289 cases without a stoma and 32 post-operative leaks (11%). In 20 patients (6.9%), fecal fistulas were repaired naturally; in 9 (3.1%), we made a diverting stoma. When the drain was inserted through the levator ani muscle, there were 2 complications (vascular lesions) (0.5%). In laparoscopic surgery (31 patients), there were 3 postoperative leaks (9.5%) treated by opening the ghost ileostomy under local anesthesia. Conclusions Inserting a drain through the levator ani muscle has, in our experience, decreased the need for constructing a diverting stoma in patients with lower rectal lesions. Furthermore when a fecal fistula is present, this drain prevents peritoneal contamination, is designated to evacuate enteric fluid and significantly ameliorates the closure of the anastomotic leak. In laparoscopic surgery, we always perform a ghost ileostomy, since rectal fistula can more easily contaminate the peritoneum surface. RADIOSENSITIZATION IN NEOADJUVANT PREOPERATIVE RADIOTHERAPY FOR LOCALLY ADVANCED FIXED OR TETHERED RECTAL CARCINOMA WITH CAPECITABINE, OXALIPLATIN, LOCAL HYPERTHERMIA AND METRONIDAZOLE

How to Place Hemoclips to Achieve Hemostasis of a Bleeding Diverticulum

Sir, We read with much interest the article by Dr. Yen regarding colonoscopic treatment of acute diverticular hemorrhage by use of endoclips. In the article the authors describe the peculiar technique of positioning hemoclips bridging the edge of the diverticulum. The clipping technique consists in applying the clip on the only fringe of the diverticular orifice, placing one prong within the adjacent mucosa and the other in the diverticulum, leaving its orifice open [1]. Although the authors did not declare any complication in the series presented, it is our opinion that such a manoeuver might be unreasonably dangerous. In fact, it is known that the wall of the diverticulum is constituted by a single mucosal layer, besides being inflamed. The introduction, mostly blind, of one of the two jaws of the clip into this cavity seems unnecessary. For several years it has been our policy to prefer compression hemostasis to injection techniques, to control diverticular bleeding. In a series of six patients recently treated, up to five hemoclips were sufficient to achieve hemostasis in all cases. Hemoclips were positioned bridging the entire diverticular orifice, in this way matching the two edges by compressing the entire enteric wall. In other words hemoclips are placed to close the whole diverticular orifice among the prongs of the clips. In this way it is possible to achieve both direct compression of the bleeding vessel, if running at the clipped edge, or at least indirect compression of the vessel. In no case was injection of any drug or any other treatment needed. One of these patients was a 77-year-old man admitted to ER for acute massive rectal bleeding. The patient was administered oral anticoagulant therapy for atrial fibrillation. Three years earlier he underwent a prophylactic left hemicolectomy for recurrent diverticulitis. On admission, hemoglobin was 9 mg/dl and INR was 2.01. Urgent colonoscopy revealed multiple diverticula throughout the entire colon with the presence of abundant blood and clots in all 70 cm of the remaining colon. A tightly adherent blood clot probably covering a diverticulum and significant blood spurting flow below it were seen 55 cm from anal verge, apparently in the transverse colon (Fig. 1a). The blood clot was removed by lavage, revealing underneath an actively bleeding diverticulum (Fig. 1b). Three hemoclips (Resolution clip; Microvasive Endoscopy, Boston Scentific, Natick, MA, USA) were placed across diverticulum until constant complete hemostasis was observed for 5 min. Hemoclips were placed to close the whole diverticular orifice among the prongs of the clips (Fig. 1c). Two hours later X-rays demonstrated no free air, and the three clips were in place distal to the hepatic flexure (Fig. 1d). No further rectal bleeding was observed, and hemoglobin levels increased to 10.5 mg/dl two days later, when the patient was discharged. Bleeding from colonic diverticula is the most common cause of acute lower gastrointestinal bleeding [2]. Despite advances in diagnostic and therapeutic technology, 10–25% of cases of lower gastrointestinal bleeding will require surgical intervention because of patient instability [3]. Colonoscopy enables simultaneous diagnosis and treatment; however, controversies exist concerning the clinical impact, timing, and modalities of application. Among the techniques available, only hemoclips treatment has been reported to control bleeding in 100% of cases [1]. This successful case series adds to those already published, A. Arezzo (&) M. Verra F. Cravero R. Reddavid M. Morino Digestive, Colorectal and Minimally Invasive Surgery, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy e-mail: alberto.arezzo@unito.it

The role of stents in the management of colorectal complications: a systematic review

BackgroundComplications in colorectal surgery include a wide range of clinical conditions, which increase mortality, morbidity, hospital stay and costs. In some cases, the placement of a self-expanding metal stent may represent a possible therapeutic strategy, avoiding further surgery.MethodsIn order to verify the feasibility and safety of the technique, we reviewed the medical literature, between January 1997 and 2015, selecting 32 studies. Inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations.ResultsThe estimated rate of early success was 73.3% (95% CI 66.3–79.3), raising from 25 to 68% in the time frame 1997–2007. The rate of early complications was 31.4% (95% CI 25.3–38.3%), progressively decreasing from 75 to 43% up to 2009. The rate of surgery for acute complication was 9.3% (95% CI 6.0–14.2%), reduced on time course from 25 to 9%. The rate of closure of dehiscence was 74.5% (95% CI 62.8–83.5%), while the rate of long-lasting success was 57.3% (95% CI 50.3–64.0%).ConclusionsEndoscopic stenting in the early postoperative management of anastomotic complications after colorectal surgery should be considered in patients with minimal risk for sepsis, as a safe and often effective alternative to surgery. However, in order to establish the safety and efficacy of this technique, prospective studies involving a larger cohort of patients are required.

Review: Therapeutic endoscopy for the treatment of anastomotic dehiscences

Anastomotic dehiscence is a major complication of surgery of the digestive tract with high morbidity and mortality rate. Its management differs, depending mainly on clinical presentation. Technological improvement allowed development of endoscopic devices that can be adopted as an alternative to surgical management in selected cases of anastomotic leakage.

Treatment of Lower-GI Post-Surgical Fistulas With the Over-the-Scope Clip

Abstract Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase morbidity and mortality. Over-the-scope clip (OTSC) application, introduced in clinical practice in 2007, represents an innovative technique to seal the visceral wall for acute and chronic colorectal post-surgical leaks and fistula management. Endoscopic closure of colorectal post-surgical leaks and fistulas with OTSC is a safe technique that accomplishes a high success rate in both acute and chronic cases, including rectovaginal, rectovesical, and colocutaneous fistulas. Overall success rate is higher than 80%, as reported in the literature, in both acute and chronic situations. No OTSC-related complications have been described in the lower gastrointestinal tract so far. This article is part of an expert video encyclopedia.