Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.

Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation:A multicenter retrospective study and a classification of gastrointestinal tract perforations

AIM:To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC)placement.METHODS:We retrospectively enrolled 20 patients(13 female and 7 male;mean age:70.6±9.8 years)in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement.Gastrointestinal tract perforation could be with oval-shape or with round-shape.Ovalshape perforations were closed by OTSC only by suction and the round-shape by the"twin-grasper"plus suction.RESULTS:Main perforation diameter was 10.1±4.3 mm(range 3-18 mm).The technical success rate was 100%(20/20 patients)and the clinical success rate was 90%(18/20 patients).Two patients(10%)who did not have complete sealing of the defect underwent surgery.Based upon our observations we propose two types of perforation:Round-shape"type-1 perforation"and oval-shape"type-2 perforation".Eight(40%)out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%).CONCLUSION:OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy.A failed closure attempt does not impair subsequent surgical treatment.

Indications and outcomes of endoscopic resection for nonpedunculated colorectal lesions:A narrative review

In the last years,endoscopic techniques gained a crucial role in the treatment of colorectal flat lesions.At the same time,the importance of a reliable assessment of such lesions to predict the malignancy and the depth of invasion of the colonic wall emerged.The current unsolved dilemma about the endoscopic excision techniques concerns the necessity of a reliable submucosal invasive cancer assessment system that can stratify the risk of the post-procedural need for surgery.Accordingly,this narrative literature review aims to compare the available diagnostic strategies in predicting malignancy and to give a guide about the best techniques to employ.We performed a literature search using electronic databases(MEDLINE/PubMed,EMBASE,and Cochrane Library).We collected all articles about endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)registering the outcomes.Moreover,we analyzed all meta-analyses comparing EMR vs ESD outcomes for colorectal sessile or nonpolypoid lesions of any size,preoperatively estimated as non-invasive.Seven meta-analysis studies,mainly Eastern,were included in the analysis comparing 124 studies and overall 22954 patients who underwent EMR and ESD procedures.Of these,eighty-two were retrospective,twenty-four perspective,nine casecontrol,and six cohorts,while three were randomized clinical trials.A total of 18118 EMR and 10379 ESD were completed for a whole of 28497 colorectal sessile or non-polypoid lesions>5-10 mm in size.In conclusion,it is crucial to enhance the preoperative diagnostic workup,especially in deciding the most suitable endoscopic method for radical resection of flat colorectal lesions at risk of underlying malignancy.Additionally,the ESD necessitates further improvement because of the excessively time-consuming as well as the intraprocedural technical hindrances and related complications.We found a higher rate of en bloc resections and R0 for ESD than EMR for non-pedunculated colorectal lesions.Nevertheless,despite the lower local recurrence rates,ESD had greater perforation rates and needed lengthier procedural times.The prevailing risk for additional surgery in ESD rather than EMR for complications or oncologic reasons is still uncertain.