Abd El Aziz, M.A.

Behm, K.T.

Grass, F.

Kelley, S.R.

English

Serveur académique lausannois

Research letterShort term oncological outcomesof completely intracorporealanastomosis after left sided roboticresections for colorectal cancerEditorCompletely intracorporeal anasto-mosis (CICA) may facilitate fasterreturn of bowel function, decreasedlength of stay, and allow flexiblespecimen extraction without com-promising intra- and postoperativecomplications1. Most studies, includ-ing two recent randomized controlledtrials focused on right-sided laparo-scopic resections2,3. However, therobotic platform may portend furtherbenefits for CICA, specifically withregards to lower conversion rates intechnically challenging procedures4.With the addition of robotics theconcept of CICA for left-sided colonand rectal resections is of interest,with the goal of translating the poten-tial benefits seen with ileocolonicresections.During right-sided resections, theactual tumour is never fully exposedto the peritoneal cavity, as both theterminal ileum and proximal colonare typically stapled off before anas-tomosis creation. The evolution ofleft-sided CICA at our institution wasbased upon creation of a fast, easilyteachable and reproducible techniquewith good short term outcomes.However, this technique potentiallyexposes the peritoneal cavity totumour cells through a controlledFig. 1 Technique Photo A shows insertion of the anvil through the controlled colotomy. Photo B shows application of the stapler withthe distal colotomy closed. Photo C shows the orientation of the Baker style anastomosisA B Ccolotomy for anvil placement. Giventhe recent moratorium on transanaltotal mesorectal excision (TaTME)secondary to high rates of localrecurrence, our institution felt itprudent to evaluate the short termoncologic outcomes of the CICAtechnique5.After institutional review boardapproval, all consecutive patients withbiopsy-confirmed colon and rectalcancer who underwent robotic left-sided colon and rectal resections withCICA between July 2015 and April2019 at Mayo Clinic, Rochester, MNwere included. All procedures wereperformed by 2 colorectal surgeonswith high volume robotic experience(K.T.B and S.R.K.). To optimize workflow, a 4 cm pfannenstiel incision ismade at the start of the operation andsecured with an Alexis™. All patientsunderwent high vascular ligation andresection according to establishedoncologic techniques. A completelyintracorporeal Baker style anasto-mosis is created utilizing a circularstapler. The anastomosis involvescreation of a 3⋅5 cm colotomy justdistal to the planned point of proxi-mal transection for anvil placement.This step occurs prior to stapling andcomplete isolation of the specimenand with that comes uncertain onco-logic risk. The colotomy is closedwith a barbed suture and the proxi-mal colon is divided with the roboticstapler (Intuitive, Sunnyvale, CA).A stapled side to end anastomosis isperformed under direct robotic vision(Fig. 1).All patients were followed accordingto the American Society of ColonAnd Rectal Surgeons (ASCRS) rec-ommendations. Only patients withat least 6 months of follow-up wereincluded. The primary outcome wasbiopsy confirmed local recurrence orintraperitoneal metastasis. Secondaryoutcomes were nodal or solid organmetastatic recurrence.Thirty-three patients were included;18 (54⋅5%) were male, with a medianage of 58⋅8 (IQR; 51 – 67) years.Most patients presented with stageII (39⋅4%) or stage III (30⋅3%) dis-ease at the time of surgery. Three(9⋅1%) patients had stage IV dis-ease with known liver and/or lungmetastases. Eighteen (54⋅5%) patientsreceived preoperative neoadjuvantradiotherapy, 14 (42⋅4%) receivedneoadjuvant chemotherapy, and 13(39⋅4%) received adjuvant chemother-apy. Patients were followed up for amedian of 16⋅5 (IQR: 11⋅3 – 20⋅7)months. No local recurrence or post-operative peritoneal metastases weredetected; five (15⋅2%) patients devel-oped distant metastases at a median of5 (range: 2 - 9) months after surgery.Of these five patients with recurrence,two originally had stage IV disease andhad curative operations for the pri-mary tumour and metastases and the© 2020 BJS Society Ltd BJS 2020; 107: e498–e499Published by John Wiley & Sons LtdDownloaded from https://academic.oup.com/bjs/article/107/11/e498/6139521 by Centre Univ. Romand de Medecine Legale CURML user on 29 November 2021Research letter e499remaining three patients had stage IIIdisease at original presentation.The present pilot study assessingshort-term oncological outcomesafter implementation of a new tech-nique for robotic CICA constructionmay help to mitigate safety concernsof local tumour spread during anvilplacement for CICA creation, longterm oncological safety needs to befurther assessed.Kevin T. Behm, Fabian Grass ,Mohamed A. Abd El Aziz and ScottR. KelleyDivision of Colon and Rectal Surgery,Mayo Clinic, Rochester, MN, USADOI: 10.1002/bjs.119551 van Oostendorp S, Elfrink A,Borstlap W, Schoonmade L, Sietses C,Meijerink J et al. Intracorporeal versusextracorporeal anastomosis in righthemicolectomy: a systematic reviewand meta-analysis. Surg Endosc 2017;31: 64–77.2 Allaix ME, Degiuli M, Bonino MA,Arezzo A, Mistrangelo M, Passera Ret al. Intracorporeal or ExtracorporealIleocolic Anastomosis AfterLaparoscopic Right Colectomy: ADouble-blinded RandomizedControlled Trial. Ann Surg 2019; 270:762–767.3 Bollo J, Turrado V, Rabal A, Carrillo E,Gich I, Martinez MC et al. Randomizedclinical trial of intracorporeal versusextracorporeal anastomosis inlaparoscopic right colectomy (IEAtrial). Br J Surg 2020; 107:364–372.4 Crippa J, Grass F, Achilli P, MathisKL, Kelley SR, Merchea A et al. Riskfactors for conversion in laparoscopicand robotic rectal cancer surgery. BrJ Surg 2020; 107: 560–566.5 Wasmuth HH, Faerden AE, MyklebustTA, Pfeffer F, Norderval S, Riis R et al.Transanal total mesorectal excision forrectal cancer has been suspended inNorway. Br J Surg 2020; 107:121–130.© 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: e498–e499Published by John Wiley & Sons LtdDownloaded from https://academic.oup.com/bjs/article/107/11/e498/6139521 by Centre Univ. Romand de Medecine Legale CURML user on 29 November 2021

Short term oncological outcomes of completely intracorporeal anastomosis after left sided robotic resections for colorectal cancer.

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Short term oncological outcomes of completely intracorporeal anastomosis after left sided robotic resections for colorectal cancer.

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