Background: Anastomotic leak rates after colorectal surgery remain high. In most left-sided colon and rectal resection surgeries, a circular stapler is utilized to create the primary bowel anastomosis. However, it remains unclear whether a relationship between circular stapler technology and anastomotic leak in left-sided colorectal surgery exists. Methods: A post-hoc analysis was conducted using a prospectively collected data set of patients from the 2017 European Society of Coloproctology snapshot audit who underwent elective left-sided resection (left hemicolectomy, sigmoid colectomy, or rectal resection) with a manual circular stapled anastomosis. Rates of anastomotic leak and unplanned intensive care unit stay in association with manual circular stapling were assessed. Patient-, disease-, geographical-, and surgeon-related factors as well as stapler brand were explored using multivariable regression models to identify predictors of adverse outcomes. Results: Across 3305 procedures, 8.0% of patients had an anastomotic leak and 2.1% had an unplanned intensive care unit stay. Independent predictors of anastomotic leak were male sex, minimal-access surgery converted to open surgery, and anastomosis height C11 (lower third rectum) (all P < 0.050). Independent predictors of unplanned intensive care unit stay were minimal-access surgery converted to open surgery and American Society of Anesthesiologists grade IV (all P < 0.050). Stapler device brand was not a predictor of anastomotic leak or unplanned intensive care unit stay in multivariable regression analysis. There were no differences in rates of anastomotic leak and unplanned intensive care unit stay according to stapler head diameter, geographical region, or surgeon experience. Conclusion: In patients undergoing left-sided bowel anastomosis, choice of manual circular stapler, in terms of manufacturer or head diameter, is not associated with rates of anastomotic leak and unplanned intensive care unit stay.

Aim The Enhanced Recovery After Surgery (ERAS (R)) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. Method An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Results Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Conclusions Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.

Objective To describe a novel end-to-end “true” reinforced stapling colorectal anastomosis and to assess surgical outcomes in a large case series of advanced cancer patients undergoing this procedure. Summary background data Anastomotic leakage (AL) remains the main concern following surgery for colorectal cancer. Methods Between September 2006 and May 2018, in the context of the Catalonian Program of Peritoneal Carcinomatosis, 1193 consecutive patients with advanced abdominal and/or pelvic tumors were included in a prospective single-center study. They underwent cytoreductive radical surgery (CRS) in most cases combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Among other surgical procedures, 374 patients underwent rectal resection and colorectal/ileorectal anastomosis, whether alone or associated to other digestive anastomosis. Key aspects of colorectal anastomosis technique were: (1) complete dissection and mobilization of the distal third of the rectum, (2) placement of a stitch that included both ends of the linear stapling of the rectal stump that was knotted on the anvil of the circular stapler, (3) “cleaning” the fatty tissue of the intestinal ends, (4) adjustment of the height of staples to the thickness of the intestinal wall, and (5) a second layer of interrupted nonperforating sutures placed circumferentially to reinforce the stapled anastomoses. A diverting stoma was not performed. Results According to clinical criteria, of the 1193 patients included, 296 cases underwent CRS (group 1) and 897 cases CRS + HIPEC (group 2). In group 1, 332 surgical procedures were performed, with 248 digestive anastomoses, of which 98 (39.5%) were colorectal anastomoses, associated to other digestive anastomosis in 37 cases. In group 2, 972 surgical procedures were performed, with 707 digestive anastomoses, of which 263 were colorectal (37.2%), 116 were associated with other digestive anastomosis . Ileocolic anastomosis was the most frequently associated digestive anastomosis. 71 major urinary reconstructions, 283 radical hysterectomies and no diverting stoma were performed. Globally, there was only three colo-ileorectal AL (3/374 = 0.8%). The overall 90-day mortality rate was 0.25%. Conclusions A technical modification to create a “true” end-to-end and completely circular reinforced anastomosis effectively prevents anastomotic leakage in patients with advanced tumors undergoing radical resection of the rectum, with no need of diverting stoma.

Peritoneal metastases of colorectal cancer are a complex entity with poor prognosis but some patients may benefit from a multidisciplinary approach that includes radical surgical resection using cytoreductive surgery (CRS). This approach remains controversial due to incomplete consensus regarding patient selection criteria, perceived high postoperative morbidity and lack of consistent survival data from current large prospective cohorts. The optimal care delivery model for patients with peritoneal metastases who may be candidates for aggressive treatments has not been defined. The aim of this study was to present the results of a population-based regional program created to optimize the management of patients with colorectal peritoneal metastases. This is a retrospective cohort study of adult patients diagnosed with colorectal cancer peritoneal metastases (PM) and treated within the peritoneal malignancies program of Catalonia. Cytoreductive surgery (with HIPEC) for colorectal cancer PM was approved by the public health authority of Catalonia in 2006, with the creation of a single referral center and well-defined practice protocols. The center is characterized by a highly specialized surgical unit and associated dedicated weekly peritoneal metastases focused multidisciplinary tumor board. All data regarding the activities of the center have been maintained in a dedicated prospective database. The intraoperative tumor burden was quantified with the peritoneal cancer index (PCI) and the completeness of surgical resection using the CCR scoring system. The data were analyzed with descriptive statistics and survival with associated predictors using the Kaplan-Meier method and the Cox proportional hazard model. A total of 523 patients, with a mean age of 60 have been treated with surgery with a curative intent. The vast majority of patients received prior systemic chemotherapy (95%) and 40% received two lines. The majority of patients had involvement of multiple abdominal regions (median 2/13), required three or more peritonectomies and one or more intestinal anastomoses. The mean PCI was 6.9/39. A complete resection (CC0) was achieved in 94% of cases. Serious postoperative morbidity was low: urgent reoperation 6.3%, postoperative return to the ICU 3.5% and 30-day readmission 4.5%. 30-day mortality was 0.4%. After a median follow-up of 27.4 months, the median survival of all patients was 42.7 months. Cumulative survival at 12 months was 92,3% (SD 1,2); at 3 years 60,3% (SD 2,5) and at 5 years 37% (SD 2,9). The peritoneum was the only site of first recurrence in 43% of cases, peritoneum with additional site(s) in 23% and other sites without involvement of the peritoneum in 34%. Increasing peritoneal tumor burden and signet ring histology were the most significant negative predictors of survival. Radical surgical resection with systemic chemotherapy is associated with excellent survival outcomes in optimally selected patients with peritoneal metastases from colon cancer. The delivery of care within a highly specialized multidisciplinary unit was associated with a very high complete resection rate and very low postoperative morbidity and mortality. This is the largest available cohort of colon cancer peritoneal metastases patients treated with contemporary systemic chemotherapy and radical surgery.

Peritoneal metastases (PM) from gastric cancer are associated with very poor survival inferior to one year in the majority of patients. Systemic chemotherapy with palliative intent is the standard treatment but a select group of patients may benefit from a more aggressive approach that includes radical surgical resection coupled with intraperitoneal chemotherapy (HIPEC). Preoperative systemic therapy has been shown to be safe prior to gastrectomy but the feasibility of gastrectomy associated with more extensive peritoneal resections and HIPEC following systemic chemotherapy is not definitively established. The aim of this study was to evaluate the results of patients undergoing gastrectomy, peritonectomy, and HIPEC following neoadjuvant systemic chemotherapy for limited gastric PM. This is a retrospective cohort study of adult patients gastric PM metastases (PM) treated within the peritoneal malignancies program of Catalonia. Patients with limited peritoneal metastases defined as peritoneal cancer index (PCI) of <12 were considered potential candidates. The standard clinical pathways included diagnostic laparoscopy, systemic chemotherapy for 4 cycles, repeat diagnostic laparoscopy prior to gastrectomy, cytoreductive surgery and cisplatin-based HIPEC. All data regarding the activities of the center have been maintained in a dedicated prospective database. There were 53 patients with a mean age of 52.2 years. In 7 patients (13.2%), PM presented as recurrent disease after a prior gastrectomy. All patients received preoperative systemic chemotherapy. Positive cytology was the indication in 9 patients (18.4%), molecular positive peritoneal lavage in 5 (10.2%). Mean affected regions were 3.6/13 and the mean PCI was 5.5/39. The majority (42/53) had a total gastrectomy with D1+ plus lymphadenectomy. Significant postoperative morbidity included: ICU readmission 1 (2.2%), hospital readmissions 8 (16%), urgent reoperation 1 (2.2%). After a median follow up of 12.1 months, 28 patients died (64.2%), 5 were alive with disease (9.4%) and 14 were disease-free (26.4%). Median survival was 20.6 months (IC 95%: 13.9 – 27.2 months) but reached 32 months in patients with a PCI of 0, complete macroscopical resection and no signet ring histology. Gastrectomy coupled with cytoreductive surgery and HIPEC is feasible and safe after neoadjuvant systemic chemotherapy in an expert center. A select group of patients with very limited peritoneal metastases and the absence of signet ring histology can be identified for whom this approach offers promising survival rates.

(rango: 40-74). El 85 % tenía una puntuación de riesgo anestésico ASA II (Rango de III-V). El estado funcional de todas las pacientes fue menor o igual a 2. El diagnóstico en 22 pacientes fue de recidiva peritoneal de cáncer ovárico y un caso de carcinoma peritoneal primario, todos con histología de ADC seroso papilar, con grados de diferenciación del 59 % indiferenciado y 49 % diferenciado. El índice de carcinomatosis peritoneal (PCI: máxima puntuación 39) obtuvo una media de 13,3 (rango: 4-36). Se alcanzó una citorreducción óptima en todos los procedimientos (CC0: 19, CC1: 6), administrando en todas ellas quimioterapia intraperitoneal intraoperatoria hipertérmica y quimioterapia intravenosa de forma simultánea. Los quimioterápicos utilizados fueron cisplatino (intraperitoneal) y 5-l uorouracilo/leucovorin (intravenoso). Después de una mediana de seguimiento de 14 meses se observo una supervivencia global de 53 % a los 5 años y la supervivencia libre de enfermedad al segundo año fue de 28 %. Se encontró morbilidad grave en el 18 % de los casos y un 8 % de mortalidad perioperatoria. Conclusiones: En pacientes seleccionados con cáncer ovárico recidivado, podrían benei ciarse de la citorreducción mas HIPEC, aportando mayores tasas de supervivencia global y libre de enfermedad con una morbilidad aceptable y mortalidad baja, comparado con los tratamientos actualmente establecidos. Se requiere más investigación en este campo para sentar las bases de lo que podría ser una nueva actitud terapéutica frente a esta compleja patología.