Violante, Tommaso

This Viewpoint reflects on a decay in surgical skill related to falling laparoscopic case volumes and describes strategies to preserve laparoscopic proficiency amid the rapid adoption of robotic platforms.

Early-onset colorectal cancer is increasing, making reproductive health an increasingly relevant survivorship issue. While immune checkpoint inhibitors have altered the management of deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) colorectal cancer, their implications for reproductive-age women remain insufficiently defined. We performed a focused narrative review, structured in line with the SANRA framework, to clarify this specific clinical domain. Immunotherapy may reshape female oncofertility counseling through two distinct mechanisms: direct reproductive uncertainty, including established endocrine toxicities and hypothesized, but currently unproven, direct gonadal effects; and indirect pathway-modifying effects, such as the potential avoidance of pelvic radiotherapy or radical surgery in selected patients with locally advanced dMMR/MSI-H rectal cancer. Anatomical organ preservation should not be automatically equated with functional fertility preservation. The key clinical message is that reproductive counseling should not be restricted to historically gonadotoxic chemotherapy. Instead, early multidisciplinary guidance should explicitly distinguish CRC-specific evidence from extrapolated or theoretical concerns, integrate fertility preservation strategies when clinically feasible, and address pelvic and sexual health, contraception, washout, endocrine follow-up, and future pregnancy planning. Until prospective CRC-specific reproductive data become available, immunotherapy should not be presented as either reproductively neutral or fertility-preserving.

Abstract Background Encountering an intra-abdominal abscess during elective surgery for Crohn disease (CD) presents a clinical dilemma. While guidelines often recommend temporary fecal diversion, stomas carry substantial morbidity. Existing literature is heavily confounded by selection bias, obscuring the true safety of bowel reconstruction. This study evaluated the safety of primary anastomosis in the presence of an intraoperative abscess. Methods A retrospective review of patients undergoing ileocecal resection for CD was conducted. To isolate the impact of the abscess and eliminate selection bias, an a priori multivariable logistic regression model and a 1:2 propensity score matched (PSM) analysis were utilized on the subcohort of patients who underwent primary anastomosis. The primary endpoint was the rate of 30-day postoperative complications. Results Among the 810 included patients (210 with an intraoperative abscess, 600 without), an abscess significantly increased operative complexity, resulting in higher rates of open conversion (29.3% vs 10.3%, P < .001) and fecal diversion (24.8% vs 6.2%, P < .001). However, multivariable analysis demonstrated that an abscess was not an independent predictor of overall 30-day complications (odds ratio [OR], 1.25; P = .190). Furthermore, in the PSM cohort of 474 patients, rates of anastomotic leak (10.1% vs 11.7%, P = .718), overall complications (41.1% vs 38.0%, P = .571), and severe complications (8.2% vs 10.8%, P = .480) were statistically identical between the abscess and non-abscess groups. Conclusion While an intraoperative abscess increases operative difficulty, it does not independently compromise anastomotic integrity. Primary anastomosis in an infected field is safe, allowing surgeons to spare appropriately selected patients at experienced centers the profound morbidity of an unnecessary stoma.

BACKGROUND: End colostomy reversal with colorectal anastomosis (Hartmann’s reversal) is a technically challenging procedure associated with significant morbidity due to adhesions and distorted anatomy after the index surgery. OBJECTIVE: To compare perioperative outcomes of open, laparoscopic, and robotic approaches for Hartmann’s reversal. DESIGN: Retrospective analysis of prospectively maintained data. SETTINGS: High-volume tertiary referral center with specialized colorectal surgery expertise. PATIENTS: A total of 218 patients who underwent Hartmann’s reversal between May 2018 and April 2023. MAIN OUTCOME MEASURES: Primary outcomes included hospital length of stay and rate of conversion. Secondary outcomes included overall complication rates and time to return of bowel function. RESULTS: Of 218 patients, 139 (63.8%) underwent open surgery, 48 (22.0%) underwent laparoscopic surgery, and 31 (14.2%) underwent robotic surgery. Robotic surgery had the lowest estimated blood loss (median 77.5 vs 100 mL laparoscopic and 150 mL open, p < 0.0001). Conversion to open surgery occurred in 16.1% of robotic cases compared with 35.4% of laparoscopic cases ( p = 0.0618). Minimally invasive approaches were associated with shorter hospital length of stay (median 3.0 vs 4.0 days, p < 0.0001) and faster return of bowel function (median 2.0 vs 3.0 days, p = 0.0095) compared to open surgery. Overall 30-day morbidity was 23.4%, with no significant difference among approaches ( p = 0.30). The temporal trend showed increasing adoption of robotic techniques, from 0% in 2018 to 53.8% in 2023, and a decrease in the proportion of cases approached by open surgery, from 76.9% in 2018 to 23.1% in 2023. LIMITATIONS: Retrospective design and single-institution experience with limited follow-up duration. CONCLUSIONS: Minimally invasive approaches to Hartmann’s reversal are associated with improved short-term outcomes compared to open surgery. The robotic approach shows promise in reducing conversion rates, potentially extending the benefits of minimally invasive surgery to more patients undergoing this challenging procedure. See Video Abstract . COMPARACIÓN DE LOS ENFOQUES ABIERTO, LAPAROSCÓPICO Y ROBÓTICO PARA LA REVERSIÓN DE HARTMANN: LA EXPERIENCIA DE LA CLÍNICA MAYO ANTECEDENTES: La reversión de la colostomía terminal con anastomosis colorrectal (reversión de Hartmann) es un procedimiento técnicamente complejo asociado a una morbilidad significativa debido a las adherencias y la distorsión anatómica tras la cirugía inicial. OBJETIVO: Comparar los resultados perioperatorios de los abordajes abiertos, laparoscópicos y robóticos para la reversión de Hartmann. DISEÑO: Análisis retrospectivo de datos mantenidos prospectivamente. ENTORNO: Centro terciario de referencia de gran volumen con experiencia especializada en cirugía colorrectal. PACIENTES: Un total de 218 se sometieron a la reversión de Hartmann entre mayo de 2018 y abril de 2023. PRINCIPALES MEDIDAS DE RESULTADOS: Los resultados primarios incluyeron la duración de la estancia hospitalaria y la tasa de conversión. Los resultados secundarios incluyeron las tasas generales de complicaciones y el tiempo de recuperación de la función intestinal. RESULTADOS: De los 218 pacientes, 139 (63,8 %) se sometieron a cirugía abierta, 48 (22,0 %) a cirugía laparoscópica y 31 (14,2 %) a cirugía robótica. La cirugía robótica tuvo la menor pérdida de sangre estimada (mediana, 77,5 ml frente a 100 ml en laparoscopia y 150 ml en cirugía abierta, p < 0,0001). La conversión a cirugía abierta se produjo en el 16,1 % de los casos robóticos frente al 35,4 % de los casos laparoscópicos ( p = 0,0618). Los abordajes mínimamente invasivos se asociaron con una estancia hospitalaria más corta (mediana de 3,0 días frente a 4,0 días, p < 0,0001) y un retorno más rápido de la función intestinal (mediana de 2,0 días frente a 3,0 días, p = 0,0095) en comparación con la cirugía abierta. La morbilidad global a los 30 días fue del 23,4 %, sin diferencias significativas entre los distintos enfoques ( p = 0,30). La tendencia temporal mostró un aumento en la adopción de técnicas robóticas, del 0 % en 2018 al 53,8 % en 2023, y una disminución en la proporción de casos abordados mediante cirugía abierta, del 76,9 % en 2018 al 23,1 % en 2023. LIMITACIONES: Diseño retrospectivo y experiencia de una sola institución con una duración de seguimiento limitada. CONCLUSIONES: Los enfoques mínimamente invasivos para la reversión de Hartmann se asocian con mejores resultados a corto plazo en comparación con la cirugía abierta. El enfoque robótico es prometedor para reducir las tasas de conversión, lo que podría ampliar los beneficios de la cirugía mínimamente invasiva a más pacientes que se someten a este procedimiento tan complejo. ( AI-generated translation ).

Abstract Background Patients with Crohn disease (CD) face an elevated risk of developing small bowel adenocarcinoma (SBA), a malignancy characterized by late-stage diagnosis and poor prognosis. In this study we aimed to characterize surgical management and oncologic outcomes for CD-associated SBA. Methods A retrospective review was conducted across 3 tertiary IBD centers, analyzing 99 patients with CD who underwent surgery for SBA between 1992 and 2025. Data included patient demographics, CD history, surgical details, and oncologic outcomes. Results The median time from CD diagnosis to SBA was 25 years. The SBA diagnosis was incidental in 74.8% of cases, discovered during surgery for other complications. Tumors were predominantly located in the ileum (80.8%) and showed aggressive features: 56.6% were poorly differentiated (grade 3), and 85.9% were pathologically advanced (T3/T4 on TNM staging). Nodal involvement was present in 45.5% of patients, and 18.2% had distant metastases at diagnosis. A complete (R0) resection was achieved in 90.9% of surgeries, with a 30-day morbidity rate of 26.3%. After a median follow-up of 36 months, the distant recurrence rate was 28.3%, and overall mortality was 27.3% (18.2% cancer related). Conclusion In patients with long-standing CD, SBA is typically an incidental diagnosis made at an advanced stage. While high rates of complete surgical resection are possible, the prognosis remains guarded due to aggressive tumor biology and high recurrence rates. These findings highlight a critical need for improved risk stratification to guide surveillance and for the development of evidence-based adjuvant treatment strategies.

Objective: This study establishes objective benchmarks for robotic ileal pouch-anal anastomosis (IPAA) proficiency, evaluating individual surgeon learning curves using risk-adjusted cumulative sum (RA-CUSUM) analysis. Summary Background Data: IPAA is a standard surgical treatment for conditions like refractory ulcerative colitis; robotic assistance offers potential advantages. However, the robotic IPAA learning curve is not clearly defined. Conventional analyses often overlook significant inter-surgeon variability and patient-specific factors, hindering surgical training optimization. Methods: A multi-site retrospective analysis of 123 consecutive robotic IPAA procedures performed by 11 surgeons between June 2015 and December 2023 was conducted. Patient-related variables were used for risk adjustment, and RA-CUSUM charts were generated to assess 30-day complications, operative time, and length of hospital stay at both aggregate and individual surgeon levels. Results: Aggregate RA-CUSUM data indicated general improvement trends for operative time and length of stay, alongside higher-than-expected complication rates in the early phase. Disaggregated analyses at the individual surgeon level revealed significant heterogeneity in performance trajectories and learning patterns across all three outcomes, directly challenging the concept of a standardized, uniform learning curve. Although postoperative complication and length of stay outcomes did not significantly differ between surgeons, operative time varied significantly. Conclusions: The acquisition of skill in robotic IPAA is a highly individualized process, suggesting the traditional uniform learning curve model is insufficient for contemporary surgical education. These findings strongly advocate for a shift towards personalized training paradigms that incorporate deliberate practice, targeted feedback, and simulation to optimize learning and patient outcomes.

Abstract Introduction Ileal pouch–anal anastomosis (IPAA) is a common surgical procedure for patients with ulcerative colitis or familial adenomatous polyposis. This study compared the outcomes of robotic, laparoscopic, and open IPAA techniques, with a focus on surgical complications and pouch failure rates. Methods A retrospective study was conducted of patients who underwent IPAA at three Mayo Clinic locations between 2015 and 2020. Data on patient demographics, surgical details, and postoperative outcomes were collected and compared across the three surgical approaches. Pouch failure was defined as the need for pouch excision or a diverting loop ileostomy. Results In all, 401 patients underwent IPAA with either an open (149, 37.2%), robotic (145, 36.2%), or laparoscopic (107, 26.7%) technique. The overall rate of pouch failure was 6.5% and did not differ significantly between the three surgical approaches. Compared with laparoscopy, robotic IPAA was associated with a lower conversion rate to open surgery (1.4 versus 17.8%; P &lt; 0.0001) and fewer 30-day readmissions (15.9% versus 28.0%; P = 0.02). However, robotic and laparoscopic IPAA approaches had higher rates of venous thromboembolism/pulmonary embolism and readmission than the open approach. Pouchitis was the most common cause of pouch failure across all surgical techniques. Conclusion Robotic IPAA had lower conversion and reduced 30-day admission rates compared with a laparoscopic approach. However, open surgery had lower rates of 30-day readmission and rates thromboembolism than robotic IPAA. The surgical approach itself does not appear to significantly impact long-term pouch failure rates.

BACKGROUND: Emergency colorectal surgery traditionally uses open approaches, with limited minimally invasive adoption. Although robotic surgery demonstrates benefits in elective procedures, its role in emergency settings remains unclear. This retrospective study evaluated outcomes of robotic vs laparoscopic and open approaches in emergency colorectal procedures and predicted future adoption trends. STUDY DESIGN: We analyzed 83,483 patients from the American College of Surgeons NSQIP database (2012 to 2021) who underwent emergency colorectal surgery: 53,731 open, 26,649 laparoscopic, and 3,103 robotic procedures. Outcomes were analyzed using multivariable regression, propensity score matching, and g-computation analysis. Classification and Regression Trees were used to analyze surgical approaches to selection factors, whereas vector autoregressive models projected future usage trends. RESULTS: Robotic surgery demonstrated significantly lower conversion rates to open surgery compared with laparoscopy (7.8% vs 24.2%; adjusted odds ratio 0.32, 95% CI 0.28 to 0.36), shorter length of stay (incidence rate ratio 0.67, 95% CI 0.65 to 0.69), and fewer surgical complications (odds ratio 0.65, 95% CI 0.60 to 0.72). Robotic usage increased from 0% to 6.6% (2012 to 2021), with trends suggesting substantial growth toward 20.2% by 2025. Patient selection favored robotics for stable patients with diverticulitis (68.4%) and cancer without sepsis, whereas open surgery remained predominant in patients with perforation, severe sepsis, or significant comorbidities. CONCLUSIONS: In selected emergency colorectal procedures, robotic surgery demonstrates superior outcomes vs conventional approaches. These outcomes may be partially influenced by patient selection factors because robotic cases involved more clinically stable patients. These findings support expanded robotic platform availability for emergency procedures, although careful patient selection remains essential. The projected increase in robotic usage reflects a growing acceptance of this technology, suggesting that its technical advantages can extend to more complex emergency cases than previously considered.

Objective: To determine if a Super Learner (SL) machine learning approach could improve the predictive accuracy of the American College of Surgeons Risk Calculator (ACS-RC) for postoperative complications in patients undergoing colorectal surgery. Summary of Background Data: Machine learning (ML) has shown significant potential to advance medical fields, including surgical risk prediction. Current tools, like the ACS-RC which uses logistic regression and extreme gradient boosting, are standard but may be enhanced by more advanced ML ensembles. Methods: This retrospective study analyzed colorectal surgery cases from the 2018-2022 ACS National Surgical Quality Improvement Program (NSQIP) database. An SL model, which combines multiple ML algorithms, was developed to predict fourteen postoperative outcomes. Its performance was compared against traditional logistic regression (LOG) and extreme gradient boosting (XGB) models. Key performance metrics included discrimination (AUROC, AUPRC) and calibration (Brier score, Hosmer-Lemeshow test). Results: The SL model demonstrated superior performance across all predicted complications when compared to both LOG and XGB. It showed superior discrimination for severe outcomes, achieving an AUROC greater than 0.94 for predicting mortality. The SL model was also more accurate in predicting infectious complications and length of stay, and its calibration metrics indicated a better overall fit and accuracy. Conclusions: The Super Learner model enhances the accuracy of postoperative risk prediction in colorectal surgery. Its superior performance suggests it is a promising tool for improving personalized patient counseling, aiding clinical decision-making, and optimizing resource allocation.