Violante, Tommaso

Lay Summary Oral vancomycin shows promise in treating pouchitis in patients with primary sclerosing cholangitis and ulcerative colitis. In this study, vancomycin helped reduce stool frequency, urgency, and incontinence. More research is needed to confirm its long-term benefits and best treatment practices.

Objective: To assess trends in surgical approaches (robotic, laparoscopic, and open) for various procedures, including prostatectomy, nephrectomy, cystectomy, colectomy, proctectomy, pancreatectomy, hepatectomy, and esophagectomy, and predict the future of these surgical approaches. Summary Background Data: The rapid adoption of robotic surgery has raised critical questions about the future of traditional laparoscopic techniques. Understanding the trends and potential dominance of robotic surgery is essential for surgical training, healthcare infrastructure, and resource allocation. Methods: This retrospective observational study utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2023. Vector Autoregressive modeling analyzed trends and predicted future patterns for robotic, laparoscopic, or open surgical approaches across the specified procedures. The study included all reported cases in the database where the surgical approach was specified. Results: The analysis revealed a continued shift towards robotic surgery, particularly dominant in urologic procedures and rapidly adopted for complex operations like hepatectomy and esophagectomy. Laparoscopy’s use is declining across most specialties, though it remains significant in colectomy. Open surgery persists at high rates, especially in pancreatic and rectal operations. Projections suggest robotic surgery will surpass laparoscopy in colectomy (44.5%) and proctectomy (38.3%) by 2026. Conclusions: The transition toward robotic surgery continues across specialties at varying rates. These findings have significant implications for surgical training, healthcare infrastructure, and resource allocation. The high rates of open surgery in certain procedures highlight opportunities for broader adoption of minimally invasive techniques.

Importance Tumor deposits have prognostic value in colon cancer, but the current American Joint Committee on Cancer (AJCC) staging only considers them if there are no concurrent positive lymph nodes. Objective To devise a staging system for colon cancer by integrating counts of tumor deposits with positive lymph nodes while retaining the current AJCC staging framework. Design, Setting, and Participants This retrospective cohort study examines data from a large-volume, tertiary care center database (January 2010 through March 2023 with follow-up until December 2023) and the population-based National Cancer Database (January 2010 through December 2020 with follow-up until December 2021). Participants were adults (age 18-75 years) with stage III colon adenocarcinoma who underwent chemotherapy, and had a specified positive lymph node count and tumor deposit count were selected. Exposure A real positive lymph nodes count was developed and used to derive Sassun-Mayo N/tumor, lymph node, and metastasis (TNM) stages that were compared with the AJCC N/TNM stages. Main Outcomes and Measures Receiver operating characteristic (ROC) curves and Kaplan-Meier analyses for 3-year overall survival were performed to assess the efficiency of the 2 staging systems. The concordance index was used for validation using the National Cancer Database. Results From a total patient number of 11 162 (institutional) and 848 704 (national), the final patient numbers were 788 and 77 790, respectively. The institutional database patients had a mean (SD) age of 58.5 (11.5) years; there were 433 male patients (54.9%) and 355 female (45.1%). The national database patients had a mean (SD) age of 59.3 (10.6) years; there were 40 315 male patients (51.8%) and 37 475 female (48.2%). ROC curve areas were improved using the Sassun-Mayo stages (3-year death for AJCC TMN, 0.63 [95% CI, 0.57-0.69] vs 0.66 [95% CI, for 0.60-0.72] for Sassun-Mayo TNM). Kaplan-Meier curves revealed visible overlaps among AJCC N stages, which were absent in the Sassun-Mayo N stages. The concordance index in the Sassun-Mayo N/TNM stages was 0.611 and 0.616, respectively, while in the AJCC N/TNM stages, it was 0.598 and 0.606, respectively. Patients upstaged from N1 to N2 (n = 10 307; 13.2%) had a 3-year overall survival rate nearly identical to that of AJCC N2a patients. Additionally, 3001 patients (3.9%) were upstaged from N2a to N2b, indicating that 13 308 patients (17.1%) with stage III colon cancer across cohorts were understaged. Conclusions and Relevance This study found that Sassun-Mayo N/TNM staging provided superior overall survival stratification compared with the current AJCC staging, suggesting that their implementation could improve prognostication in colon cancer.

AbstractAimMinimally invasive transanal platforms are now the standard of care for select low‐risk rectal tumours. However, existing platforms come with persistent technical challenges. The da Vinci SP Surgical System™ offers a new alternative designed to work effectively in narrow spaces. This technology has the potential to enhance the feasibility and proximal extent of complex transanal resections. This study aimed to describe the morbidity and technical success in patients undergoing single‐port robotic transanal minimally invasive surgery (SPR‐TAMIS). Secondary outcomes include rates of local recurrence.MethodsA retrospective analysis was conducted on all patients who underwent SPR‐TAMIS at our institution between February 2019 and December 2023.ResultsThe study included 31 patients (19 men, 12 women) with a mean age of 61 ± 13.3 years. The average tumour distance from the anal verge was 10 cm. Thirty patients completed SPR‐TAMIS, with one patient requiring conversion to robotic sigmoidectomy due to location in the mid‐sigmoid colon. The mean operating time was 106 ± 42 min. Twenty‐eight out of 30 patients underwent full‐thickness excision and all but two were successfully closed. All specimens were resected intact, and margins were negative in 93.5% of cases. The average tumour size was 13 ± 34 cm2, with 13 lesions classified as adenomas and 16 as adenocarcinomas. All patients who did not undergo associated procedures were discharged on the day of surgery. Two patients experienced 30‐day morbidity. At a mean follow‐up of 18 months (± 13), no local or systemic recurrences were identified.ConclusionSPR‐TAMIS for excision of low‐risk rectal tumours is associated with high rates of technical success and low 30‐day morbidity. Further research is needed to compare SPR‐TAMIS with other techniques to determine potential advantages over current transanal platforms.

Objective: To compare robotic-assisted proctectomy with ileal pouch-anal anastomosis (R-IPAA) outcomes and laparoscopic proctectomy with IPAA within a specialized robotic surgery center, using matching techniques to minimize potential confounding factors. Background: Minimally invasive approaches, particularly laparoscopy, have improved outcomes for patients with inflammatory bowel disease and familial adenomatous polyposis undergoing IPAA. Robotic-assisted surgery offers potential technical advantages, but its definitive superiority over laparoscopy in this context remains under debate. Methods: This retrospective, “Strengthening the Reporting of Observational Studies in Epidemiology”–compliant study analyzed 234 consecutive patients undergoing IPAA (117 robotic and 117 laparoscopic). Data encompassed patient demographics, intraoperative details, and postoperative outcomes. We employed various matching techniques to address potential bias. Primary endpoints focused on 30-day complications, readmissions, and reoperations, with secondary endpoints including hospital stay, blood loss, and stoma closure rates. Results: R-IPAA demonstrated a lower conversion rate to open surgery ( P = 0.02), a shorter hospital stay ( P = 0.04), and reduced blood loss ( P = 0.0003) compared with laparoscopic proctectomy with IPAA. While overall 30-day morbidity rates were similar ( P = 0.4), matched analyses suggested a trend towards fewer reoperations and 3-month IPAA-associated complications after diverting loop ileostomy closure in the robotic group. However, these differences did not reach statistical significance. Conclusions: In a high-volume robotic surgery center, R-IPAA reduced the risk of conversion to open surgery while reducing intraoperative blood loss and providing shorter lengths of stay with equivalent perioperative outcomes. Promising trends to reduce 30-day reoperations and surgical complications after diverting loop ileostomy closure were observed after a matching analysis.

BACKGROUND: IPAA has become the criterion standard for treating ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn’s colitis. Robotic surgery promises improved postoperative outcomes and decreased length of stay. However, few studies have evaluated the benefits of robotic IPAA compared to laparoscopy. OBJECTIVE: To compare short-term 30-day postoperative outcomes of robotic versus laparoscopic proctectomy with IPAA and diverting loop ileostomy. DESIGN: Retrospective observational study from a single, high-volume center. SETTINGS: Mayo Clinic, Rochester, Minnesota (tertiary referral center for IBD). PATIENTS: All adult patients undergoing minimally invasive proctectomy with IPAA and diverting loop ileostomy between January 2015 and April 2023. MAIN OUTCOME MEASURES: Thirty-day complications, hospital length of stay, estimated blood loss, conversion rate, 30-day readmission, and 30-day reoperation. RESULTS: Two hundred seventeen patients were included in the study; 107 underwent robotic proctectomy with IPAA and diverting loop ileostomy, whereas 110 had laparoscopic proctectomy with IPAA and diverting loop ileostomy. Operating time was significantly longer in the robotic group (263 ± 38 vs 228 ± 75 minutes, p < 0.0001). The robotic group also had lower estimated blood loss (81.5 ± 77.7 vs 126.8 ± 111.0 mL, p = 0.0006) as well as fewer conversions (0% vs 8.2%, p = 0.003). Patients in the robotic group received more intraoperative fluids (3099 ± 1140 vs 2472 ± 996 mL, p = 0.0001). However, there was no difference in length of stay, 30-day morbidity, 30-day readmission, 30-day reoperation, rate of diverting loop ileostomy closure at 3 months, and surgical IPAA complication rate after ileostomy closure. LIMITATIONS: Retrospective design, single-center study, potential bias because of the novelty of the robotic approach, and lack of long-term and quality-of-life outcomes. CONCLUSIONS: Robotic proctectomy with IPAA and diverting loop ileostomy may offer advantages in terms of estimated blood loss and conversion rate while maintaining the benefits of minimally invasive surgery. Further research is needed to evaluate long-term outcomes. See Video Abstract. NAVEGANDO EL PROGRESO: EXPERIENCIA DE OCHO AÑOS EN UN SOLO CENTRO CON PROCTECTOMÍA MÍNIMAMENTE INVASIVA Y ANASTOMOSIS ANAL-BOLSA ILEAL ANTECEDENTES: La anastomosis anal-bolsa ileal (IPAA) se ha convertido en el estándar de oro para el tratamiento de la colitis ulcerosa, la poliposis adenomatosa familiar y casos seleccionados de colitis de Crohn. La cirugía robótica promete mejores resultados posoperatorios y una menor duración de la estancia hospitalaria. Sin embargo, pocos estudios han evaluado los beneficios de la IPAA robótica en comparación con la laparoscopia. OBJETIVO: Comparar los resultados postoperatorios a corto plazo a 30 días de la proctectomía robótica versus laparoscópica con IPAA e ileostomía en asa de derivación. DISEÑO: Estudio observacional retrospectivo de un único centro de gran volumen. AJUSTES: Mayo Clinic, Rochester, Minnesota (centro terciario de referencia para EII). PACIENTES: Todos los pacientes adultos sometidos a proctectomía mínimamente invasiva con IPAA y DLI entre Enero de 2015 y Abril de 2023. PRINCIPALES MEDIDAS DE RESULTADOS: Complicaciones a los 30 días, duración de la estancia hospitalaria, pérdida de sangre estimada, tasa de conversión, reingreso a los 30 días y reoperación a los 30 días. RESULTADOS: Se incluyeron en el estudio 217 pacientes; 107 se sometieron a proctectomía robótica con IPAA y DLI, mientras que 110 se sometieron a proctectomía laparoscópica con IPAA y DLI. El tiempo operatorio fue significativamente mayor en el grupo robótico (263 ± 38 minutos versus 228 ± 75 minutos, p < 0,0001); la pérdida de sangre estimada (EBL) fue menor en el grupo robótico (81,5 ± 77,7 ml versus 126,8 ± 111,0 ml, p = 0,0006), así como el número de conversiones (0% versus 8,2%, p = 0,003). Los pacientes del grupo robótico recibieron más líquidos intraoperatorios (3099 ± 1140 ml versus 2472 ± 996 ml, p = 0,0001). Sin embargo, no hubo diferencias en la duración de la estancia hospitalaria, la morbilidad a los 30 días, el reingreso a los 30 días, la reoperación a los 30 días, la tasa de cierre del DLI a los tres meses y la tasa de complicaciones quirúrgicas de la IPAA después del cierre de la ileostomía. LIMITACIONES: Diseño retrospectivo, estudio unicéntrico, posible sesgo debido a la novedad del enfoque robótico, falta de resultados a largo plazo y de calidad de vida. CONCLUSIONES: La proctectomía robótica con IPAA y DLI puede ofrecer ventajas en términos de EBL y tasa de conversión, manteniendo al mismo tiempo los beneficios de la cirugía mínimamente invasiva. Se necesita más investigación para evaluar los resultados a largo plazo. (Traducción—Dr. Yesenia Rojas-Khalil)

Objective: To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer. Background: Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data are crucial for continuous improvement. Previous studies suggest cumulative sum charts hold promise in identifying performance trends and outliers. Methods: This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at 2 institutions. RA-CUSUM charts were generated for 3 outcomes: (1) complications, (2) operative time, and (3) length of stay. Results: The overall RA-CUSUM curves for operative time and complications showed an initial learning phase, followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while 5 minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins. Conclusions: The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality.

Objective: This study aims to assess the costs of a same-day discharge (SDD) enhanced recovery pathway for diverting loop ileostomy (DLI) closure compared with a standard institutional enhanced recovery protocol. Background: Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020. Methods: A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing SDD DLI closure from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient enhanced recovery protocol. Patients were matched based on age, sex, american society of anesthesiologists score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days postdischarge. Results: The SDD group (n = 118) demonstrated a significant reduction in median index episode hospitalization and 30-day postoperative costs compared with the inpatient group (n = 236), with savings of $4827 per patient. Complication rates were similar, and so were readmission and reoperation rates. Conclusions: Implementation of the SDD for DLI closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards SDD protocols, offering economic benefits and potential improvements in health care resource utilization.

BACKGROUND: The COVID-19 pandemic has severely affected healthcare systems globally, resulting in significant delays and challenges in various medical treatments, particularly in cancer care. This study aims to investigate the repercussions of the pandemic on surgical interventions for colorectal cancer (CRC) in the US, using data from the National Cancer Database. STUDY DESIGN: We conducted a retrospective analysis of the National Cancer Database, encompassing adult patients who underwent surgical procedures for colon and rectal cancer in 2019 (pre-COVID) and 2020 (COVID). We examined various demographic and clinical variables, including patient characteristics, tumor staging, surgical approaches, and socioeconomic factors. RESULTS: The analysis included 105,517 patients, revealing a 17.3% reduction in surgical cases during the initial year of the pandemic. Patients who underwent surgery in 2020 displayed more advanced clinical and pathological tumor stages compared to those treated in 2019. After diagnosis, no delay was reported in the treatment. Patients operated during the pandemic, Black patients, uninsured, and Medicaid beneficiaries had worse stage colon and rectal cancer, and individuals with lower incomes bore the burden of advanced colon cancer. CONCLUSIONS: The impact of the COVID-19 pandemic on CRC surgery transcends a mere decline in case numbers, resulting in a higher prevalence of patients with advanced disease. This study underscores the exacerbated disparities in cancer care, particularly affecting vulnerable populations. The COVID-19 pandemic has left a significant and enduring imprint on CRC surgery, intensifying the challenges faced by patients and healthcare systems. Comprehensive studies are imperative to comprehend the long-term consequences of delayed screenings, diagnoses, and treatments as healthcare planning for the future must consider the unintended repercussions of pandemic-related disruptions.