Rottoli, Matteo

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.

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.