Low anterior resection syndrome: An unavoidable price to pay to preserve the rectum?

Cáncer de recto; Cirugía rectal; Neuromodulación sacraCàncer de recte; Cirurgia rectal; Neuromodulació sacraRectal cancer; Rectal surgery; Sacral neuromodulatio

Diversity bias in colorectal surgery: a global perspective

Colorectal surgery; Diversity; RaceCirugía de colon y recto; Diversidad; RazaCirurgia de còlon i recte; Diversitat; RaçaThere is a specific lack of data on equity and injustices among colorectal surgeons regarding diversity. This study aimed to explore colorectal surgeon’s lived experience of diversity bias with a specific focus on gender, sexual orientation or gender identity and race or religion. A bespoke questionnaire was designed and disseminated to colorectal surgeons and trainees through specialty association mailing lists and social media channels. Quantitative and qualitative data points were analysed. 306 colorectal surgeons responded globally. 58.8% (n = 180) identified as male and 40.5% (n = 124) as female. 19% were residents/registrars. 39.2% stated that they had personally experienced or witnessed gender inequality in their current workplace, 4.9% because of sexual orientation, and 7.5% due to their race or religion. Sexist jokes, pregnancy-related comments, homophobic comments, liberal use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. 44.4% (n = 135) did not believe their institution of employer guaranteed an environment of respect for diversity and only 20% were aware of society guidelines on equality and diversity. Diversity bias is prevalent in colorectal surgery. It is necessary to work towards real equality and inclusivity and embrace diversity, both to promote equity among colleagues and provide better surgical care to patients.Open access funding provided by Università degli Studi della Campania Luigi Vanvitelli within the CRUI-CARE Agreement. All authors have no source of funding

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

Emergency surgery; Laparoscopy; Minimally invasive surgeryCirugía de emergencia; Laparoscopia; Cirugía mínimamente invasivaCirurgia d'urgència; Laparoscòpia; Cirurgia mínimament invasivaBackground Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS. Methods This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements. Results Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20–107) depending on the initial surgeon’s experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon’s proficiency. Conclusions Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research

Outcomes of Intra- versus Extra-Corporeal Ileocolic Anastomosis after Minimally Invasive Right Colectomy for Cancer: An Observational Study

Càncer colorectal; Anastomosi extracorpòria; Col·lectomia dreta mínimament invasivaCáncer colorrectal; Anastomosis extracorpórea; Colectomía derecha mínimamente invasivaColorectal cancer; Extracorporeal anastomosis; Minimally invasive right colectomyIntracorporeal anastomoses (IA) are increasingly being used in colorectal surgery. Some data suggest that these might confer benefits compared with extracorporeal anastomoses (EA). The aim of this study is to compare the short-term complications associated with IA versus EA for minimally invasive right colectomy. This is a single-centre, retrospective study on a prospective database. Patients who underwent minimally invasive right colectomy for cancer between January 2017 and December 2019 were assessed for inclusion. The primary outcome was global 30-day morbidity. Overall, 189 patients were included, of whom 102 had IA. Global morbidity and medical complications were higher in patients with EA (23.5% vs. 40.2%, p = 0.014; 5.9% vs. 14.9%, p = 0.039, respectively). None of the patients with IA had non-infectious surgical wound complications, compared to 4.6% in the EA group (p = 0.029). No differences were found in anastomotic leakage (9.8% vs. 10.3%, p = 0.55). At multivariable analysis, EA was an independent risk factor for both surgical (OR = 3.71 95% CI: 1.06–12.91, p = 0.04) and overall complications (OR = 3.58 95% CI: 1.06–12.12, p = 0.04). IA lowers the risk for global, medical, and surgical complications with minimum risk for wound complications, without increasing the risk of ALThis research received no external funding

Use of sponge-assisted endoluminal vacuum therapy for the treatment of colorectal anastomotic leaks: expert panel consensus

Colorectal anastomotic leaks; Endoluminal vacuum therapyFugas anastomóticas colorrectales; Terapia de vacío endoluminalFuites anastomòtiques colorectals; Teràpia de buit endoluminalBackground Anastomotic leaks represent one of the most significant complications of colorectal surgery and are the primary cause of postoperative mortality and morbidity. Sponge-assisted endoluminal vacuum therapy (EVT) has emerged as a minimally invasive technique for the management of anastomotic leaks; however, there are questions regarding patient selection due to the heterogeneous nature of anastomotic leaks and the application of sponge-assisted EVT by surgeons. Method Seven colorectal surgical experts participated in a modified nominal group technique to establish consensus regarding key questions that arose from existing gaps in scientific evidence and the variability in clinical practice. After a bibliographic search to identify the available evidence and sequential meetings with participants, a series of recommendations and statements were formulated and agreed upon. Results Thirty-seven recommendations and statements on the optimal use of sponge-assisted EVT were elaborated on and unanimously agreed upon by the group of experts. The statements and recommendations answer 10 key questions about the indications, benefits, and definition of the success rate of sponge-assisted EVT for the management of anastomotic leaks. Conclusion Although further research is needed to resolve clinical and technical issues associated with sponge-assisted EVT, the recommendations and statements produced from this project summarize critical aspects to consider when using sponge-assisted EVT and to assist those involved in the management of patients with colorectal anastomotic leaks.This project was supported by B. Braun Surgical SAU

The Gut Microbiota Metabolite Succinate Promotes Adipose Tissue Browning in Crohn’s Disease

Succinic acid; Bacteria translocation; Beige adipose tissueÀcid succínic; Translocació de bacteris; Teixit adipós beigeÁcido succínico; Translocación de bacterias; Tejido adiposo beigeBackground and Aims Crohn’s disease [CD] is associated with complex microbe–host interactions, involving changes in microbial communities, and gut barrier defects, leading to the translocation of microorganisms to surrounding adipose tissue [AT]. We evaluated the presence of beige AT depots in CD and questioned whether succinate and/or bacterial translocation promotes white-to-beige transition in adipocytes. Methods Visceral [VAT] and subcutaneous [SAT] AT biopsies, serum and plasma were obtained from patients with active [n = 21] or inactive [n = 12] CD, and from healthy controls [n = 15]. Adipose-derived stem cells [ASCs] and AT macrophages [ATMs] were isolated from VAT biopsies. Results Plasma succinate levels were significantly higher in patients with active CD than in controls and were intermediate in those with inactive disease. Plasma succinate correlated with the inflammatory marker high-sensitivity C-reactive protein. Expression of the succinate receptor SUCNR1 was higher in VAT, ASCs and ATMs from the active CD group than from the inactive or control groups. Succinate treatment of ASCs elevated the expression of several beige AT markers from controls and from patients with inactive disease, including uncoupling protein-1 [UCP1]. Notably, beige AT markers were prominent in ASCs from patients with active CD. Secretome profiling revealed that ASCs from patients with active disease secrete beige AT-related proteins, and co-culture assays showed that bacteria also trigger the white-to-beige switch of ASCs from patients with CD. Finally, AT depots from patients with CD exhibited a conversion from white to beige AT together with high UCP1 expression, which was corroborated by in situ thermal imaging analysis. Conclusions Succinate and bacteria trigger white-to-beige AT transition in CD. Understanding the role of beige AT in CD might aid in the development of therapeutic or diagnostic interventions.This study was supported by grants from the Spanish Ministry of Science and Innovation [PI18/00037 (Instituto de Salud Carlos III, ISCIII) to C.S.; PI17/01503 and PI20/00338 (ISCIII) to J.V. and RTI2018-093919 to S.F.-V.], co-financed by the European Regional Development Fund [ERDF] and a European Crohn’s and Colitis Organization grant to C.S. The Spanish Biomedical Research Center in Diabetes and Associated Metabolic Disorders [CIBERDEM] [CB07708/0012] is an initiative of the Instituto de Salud Carlos ISCIII acknowledges support from the ‘Ramón y Cajal’ programme from the Ministerio de Educación y Ciencia [RYC2013-13186], co-financed by the ERDF. S.F.-V. acknowledge support from the ‘Miguel Servet’ tenure track programme [CP10/00438, CPII16/0008] from the Fondo de Investigación Sanitaria, co-financed by the ERDF. D.M.-F. acknowledges support from PERIS-PFI-Salut SLT01720000021

Anti-TNF Therapies Suppress Adipose Tissue Inflammation in Crohn’s Disease

Adalimumab; Adipose tissue; InfliximabAdalimumab; Tejido adiposo; InfliximabAdalimumab; Teixit adipós; InfliximabAnti-TNF biologics have been shown to markedly improve the quality of life for patients with Crohn’s disease (CD), yet one-third of patients fail to benefit from this treatment. Patients with CD develop a characteristic wrapping of visceral adipose tissue (VAT) in the inflamed intestinal area, termed creeping fat, and it is known that adipose tissue expansion influences the efficacy of anti-TNF drugs. We questioned whether anti-TNF therapies impact the creeping fat in CD, which might affect the outcome of the disease. Adipose tissue biopsies were obtained from a cohort of 14 patients with CD that received anti-TNF drugs and from 29 non-anti-TNF-treated patients (control group) matched by sex, age, and body mass index undergoing surgical interventions for symptomatic complications. We found that anti-TNF therapies restored adipose tissue morphology and suppressed immune cell infiltration in the creeping fat. Additionally, anti-TNF treatments appeared to markedly improve the pro-inflammatory phenotype of adipose-tissue macrophages and adipose-tissue-derived stem cells. Our study provides evidence that anti-TNF medications influence immune cells and progenitor cells in the creeping of patients with CD, suppressing inflammation. We propose that perilesional VAT should be considered when administering anti-TNF therapy in patients with CD.This study was supported by a grant from the Spanish Ministry of Economy and Competitiveness (PI18/00037 to C.S.), co-financed by the European Regional Development Fund (ERDF). C.S. acknowledges support from the “Ramón y Cajal” program from the Ministerio de Educación y Ciencia (RYC2013-13186), co-financed by the ERDF. A.B.-T. acknowledges support from PI-AGAUR 2022-B00577. D.M.-F. acknowledges support from PERIS-PFI-Salut SLT01720000021

Cost-Effectiveness of Robotic vs. Laparoscopic Surgery for Different Surgical Procedures: Protocol for a Prospective, Multicentric Study (ROBOCOSTES)

Cost-effectiveness; Laparoscopic surgery; Multicenter studiesRendibilitat; Cirurgia laparoscòpica; Estudis multicèntricsRentabilidad; Cirugía laparoscópica; Estudios multicéntricosBackground: The studies which address the impact of costs of robotic vs. laparoscopic approach on quality of life (cost-effectiveness studies) are scares in general surgery. Methods: The Spanish national study on cost-effectiveness differences among robotic and laparoscopic surgery (ROBOCOSTES) is designed as a prospective, multicentre, national, observational study. The aim is to determine in which procedures robotic surgery is more cost-effective than laparoscopic surgery. Several surgical operations and patient populations will be evaluated (distal pancreatectomy, gastrectomy, sleeve gastrectomy, inguinal hernioplasty, rectal resection for cancer, Heller cardiomiotomy and Nissen procedure). Discussion: The results of this study will demonstrate which treatment (laparoscopic or robotic) and in which population is more cost-effective. This study will also assess the impact of previous surgical experience on main outcomes.Project PI20/00008, funded by Instituto de Salud Carlos III (ISCIII) and co-funded by the European Union

A European survey on the insights of patients living with metastatic colorectal cancer: the patient journey before, during and after diagnosis - an Eastern European perspective

Background: Despite being highly preventable and treatable if diagnosed early, colorectal cancer (CRC) remains the second leading cause of cancer-related death in Europe. Limited information is available from the patient perspective on the persisting unmet needs of the journey of the patient with CRC. Objective: To capture European metastatic CRC (mCRC) patients' insights during the patient journey (prediagnosis; diagnosis; postdiagnosis) through a patient survey. Methods: In total, 883 patients from 15 European countries participated. Participants were divided into four groups from Hungary, Poland, Serbia and 'other European countries' (n=103, 163, 170 and 447 patients, respectively). Results: General awareness of CRC and its symptoms prediagnosis varied among groups, with patients from Poland recording the lowest levels. Screening practices and attitudes also varied; while more patients from Serbia had been invited to CRC screening (~15%) compared with the other groups, the ones not invited claimed mostly (~20%) that would not have attended if they had been invited. Whereas most patients were diagnosed within a month after the first consultation/positive screening, the percentages varied substantially being lowest among patients in Poland (~30%) and Serbia (~25%). Although CRC-related information provision varied, with most informed patients from Hungary (~90%) and least from Serbia (~50%), all groups requested an easier-to-understand language by the healthcare team. Approximately 50% of patients from Eastern Europe had to wait longer than a month to receive treatment, in contrast to ~30% from other European countries. All groups emphasised the unmet need for support from psychologists and other patients. Conclusions: Our survey reveals the key aspects of the journey of the patient with mCRC and highlights the areas of similarities and differences between patients with mCRC from Eastern Europe versus those from other European countries as well as among patients from different Eastern European countries, calling for improvement particularly around awareness, screening, treatment availability, communication and support networks