For high-risk patients receiving right-sided colectomy, stoma formation is a safety strategy. Options are anastomosis with loop ileostomy, end ileostomy, or split stoma. The aim is to compare the outcome of these three options. This retrospective cohort study included all patients who underwent right sided colectomy and stoma formation between January 2008 and December 2021 at two tertial referral centers in Switzerland. The primary outcome was the stoma associated complication rate within one year. A total of 116 patients were included. A total of 20 patients (17

Abstract Objective Comparing different surgical guidelines for recurrent uncomplicated diverticulitis, a careful benefit-risk assessment is recommended although different approaches giving the indication for surgery exists. The purpose of this study was to evaluate the impact of indications-specific strategies on surgical outcomes allowing adequate benefit-risk consulting. Methods All patients undergoing elective colonic resection for diverticulitis between January 2011 and March 2020 in our institution were included. They were divided into two groups based on the strategy for surgical indication: relative surgery indication group (RSI; CDD (classification of diverticula disease) Type 2a, 3a and 3b, n = 585) and absolute surgery indication group (ASI; CDD Type 2b and 3c, n = 318). Propensity score-matching (PSM) was applied at a ratio of 1:1 to compare the RSI and the ASI group. Results In the univariate analysis, RSI patients were younger (62±10.4 vs. 67.7±11.4, p<0.05), had a higher physical status (ASA score 1 or 2 in 80.7% vs. 60.8%, p<0.05), were less immunosuppressed (3.4% vs. 6.9%, p<0.05) and suffered less from coronary heart disease (3.8% vs. 7.2%, p<0.05). After PSM, 318 vs. 318 patients were selected and baseline characteristics resulted comparable. The proportion of laparoscopic resection was 94.7% in RSI versus 84.6% in ASI (p<0.05) and the conversion rate to open surgery for laparoscopic resection was 5.0% in RSI and 13.8% in ASI (p<0.05). Intraoperative complications were rare in both groups (3.1% vs. 5.3%, p=0.24). Mean operation time was shorter in RSI (211±62 vs. 229±72, p<0.05). Major morbidity (Clavien/Dindo ≥3b) occurred less frequently in RSI (3.8% vs. 10.1%, p<0.05) and the overall comprehensive complications index (CCI) was lower in RSI (9.4±12.2 vs. 12.9±14.9, p<0.05). Anastomotic insufficiency occurred in 0.9% in RSI and in 2.5% in ASI (p=0.22). A defunctioning stoma was received by 0.9% in RSI and 11.0% in ASI (p<0.05). Conclusion Our study demonstrates that even after PSM analysis patients with RSI in contrast to patients with more advanced diverticular disease have a lower risk of suffering from postoperative overall morbidity and major morbidities as well as the risk of receiving a temporary stoma. These observations should be considered when counselling patients with an equivocal indication for surgery for diverticular disease.

We introduced robotic-assisted Ivor Lewis esophagectomies (rob-E) using the da Vinci Xi in Oct. 2015. Prior to that, esophagectomies were performed as open Ivor Lewis (open-E) procedures. Aim of this study is to evaluate the safety of rob-E in comparison to open-E procedures regarding perioperative outcomes. Retrospective analysis of prospectively collected data between Feb. 1999 and Dec. 2020. A case-matched analysis, matching open-E to rob-E in a 1:1 manner, was conducted. Cases were matched regarding age, gender, American Society of Anesthesiologists (ASA) score, histological type of tumor, tumor location and stage. In the study period 321 patients underwent an esophagectomy. 76 received rob-E and 245 open-E. After matching the cases the comparison of preoperative patient and tumor characteristics revealed no differences between the rob-E and open-E group regarding age at time of operation with a median of 69.5 (35-83) respectively 70 (46-88) years (p = 0.900), gender with 84.2% male in both groups (p = 1.000), ASA score with 68.4% ASA 3 or 4 in both groups (p = 1.000), percentage of tumor stage III of 53.9% respectively 57.9% (p = 0.707), and rate of neoadjuvant treatment of 82.9% in rob-E and 81.6% in open-E (p = 1.000). Conversion from rob-E to open-E was never necessary. For rob-E versus open-E no difference was found regarding overall morbidity with 69.7% versus 60.5% (p = 0.307), major morbidity (Clavien-Dindo > = 3b) with 11.8% versus 14.5% (p = 0.811), incidence of anastomotic insufficiency with 7.9% versus 5.3% (p = 0.745), rate of surgical reintervention with 5.3% versus 7.9% (p = 0.745), and mortality with 2.6% versus 3.9% (p = 1.000). Postoperative details showed no difference including a similar duration of hospitalization with a median of 20 (13-62) respectively 18.5 (13-52) days (p = 0.368) and number of harvested lymph nodes with a median of 24.5 (7-59) in rob-E and 23 (2-64) in open-E (p = 0.203). The introduction of rob-E in our institution was safe, as perioperative morbidity and mortality did not differ from the previously performed open-E. Overall, the incidence of major morbidity and anastomotic insufficiency in rob-E and open-E show a satisfactory rate compared to previous reports in literature. Further studies with a larger cohort of rob-E are planned in order to draw more decisive conclusions.

Abstract Objective We introduced robotic-assisted Ivor Lewis esophagectomies (rob-E) using the da Vinci Xi in Oct. 2015. Two anastomotic techniques have been performed – continuously sutured (COSU) and linear-stapled (LIST). Aim of this study is to evaluate the two anastomotic techniques regarding perioperative outcomes in our experience. Methods Retrospective analysis of prospectively collected data between Oct. 2015 and Dec. 2020 including 76 patients. 45 underwent COSU and 31 LIST. Techniques are demonstrated with video material. Minor (Clavien-Dindo < = 3a) and major (Clavien-Dindo > = 3b) morbidity, rate of anastomotic insufficiency, mortality, and duration of hospitalization were compared. Results Patient characteristics were as follows: median age of 69 (35-83) years in COSU and 70 (36-83) years in LIST (p = 0.575), male gender in 84.4% of COSU and 83.9% of LIST (p = 1.000), and physical status with American Society of Anesthesiologists score 3 in 62.2% of COSU and 67.7% of LIST (p = 0.771). Concerning tumor characteristics there were 91.1% adenocarcinomas in COSU and 96.8% in LIST (p = 0.642), whereas the others were squamous cell carcinomas and one neuroendocrine tumor in COSU. The tumors were stage II in 22.2% respectively 32.3% and stage III in 57.8% respectively 48.4% of COSU and LIST (p = 0.555). Comparison of minor morbidity occurring in 60.0% of COSU and 54.8% of LIST (p = 0.813), major morbidity in 8.9% respectively 16.1% (p = 0.473), incidence of anastomotic insufficiency in 8.9% of COSU and 6.5% of LIST (p = 1.000), rate of surgical reintervention necessary in 2.2% respectively 9.7% (p = 0.298) as well as mortality of 2.2% in COSU and 3.2% in LIST (p = 1.000) showed no difference. Median duration of hospitalization of 20 (13-49) days in COSU and 20 (14-62) in LIST (p = 0.423) did not differ. Conclusion In rob-E COSU and LIST show comparable results and a preferable technique cannot be determined yet. Our results do not support the results of previous reports (Cerfolio et al.) that demonstrated a superiority of LIST. While stapling the backside of the anastomosis in LIST impresses as an elegant way to overcome the surgical demanding part of the anastomosis, other disadvantages such as compromising perfusion of the gastric conduit may prevail and limit the benefits. Further studies with a larger cohort are planned in order to draw more decisive conclusions.

Abstract Objective Outpatient hemorrhoid surgery is a topic of growing importance with a need of modifications to pain management to enable early discharge. Opioid free anesthesia and analgesia (OFAA) has the goal to reduce postoperative pain as well as to improve discharge circumstances. The impact of OFAA on patients receiving ambulatory hemorrhoidectomy is investigated. Methods A retrospective cohort study on ambulatory hemorrhoidectomy between 2018 and 2020 was performed and patients that did and did not receive OFAA were compared. In the OFAA group patients received spinal anesthesia with Takipril and hyperbaric technique. Additionally Metamizole 500mg i.v. and Paracetamol 1g i.v. was used. In the non-OFAA group opioids were administered intravenously (fentanyl or remifentanyl) and sublingual (buprenorphin). Primary endpoint was pain measured according to a numeric rating scale (NRS) one hour postoperatively. Secondary endpoints were pain 24 hours postoperative, duration of hospital stay, urinary retention, postoperative nausea and vomiting (PONV), overall morbidity, and re-admission. Wilcoxon Rank-Sum test was performed to search for differences between the outcomes. Results 117 patients were included in the analysis. 41 percent of the patients were female. The mean age was 54±14 years. 40 patients did not receive opioids perioperatively (OFAA group) and 77 did (non-OFAA group). The non-OFAA group received a mean dose of 23.3±17.9 mg morphine equivalent. Median NRS score one hour postoperatively was 0 (interquartile range 0-1) for OFAA and 2 (0-4) for non-OFAA (p = 0.01). The median NRS score 24 hours postoperatively was 1 (0-2) for OFAA and 1 (0-3) for non-OFAA (p = 0.40). There were 3 patients (7.5%) with urinary retention in OFAA and 5 patients (6.5%) in non-OFAA(p = 0.84).No patient had PONV in OFAA and 5 (6.5%) in non-OFAA (p = 0.10). The overall morbidity was 5 (12.5%) in OFAA and 16 (20.8%) in non-OFAA (p = 0.27). There were two readmissions (5%) in OFAA and 6 (7.8%) in non-OFAA (p = 0.58). Conclusion There is a significant difference in pain one hour postoperatively between OFAA and non-OFAA with a clear benefit of not administering opioids. Opioids may trigger pelvic floor spasms and disimprove postoperative pain. In the context of outpatient surgery, we recommend an opioid free operation to reduce postoperative pain and improve discharge prerequisites.

Colorectal cancer continues to be the third most common cancer and constitutes the second leading cause of cancer-associated death among adults in the western societies. Despite the improvement of multimodality treatment with surgical resection and chemo-radiation, disease recurrence either as local recurrence or metastatic disease represents a major cause of significant cancer-associated morbidity and mortality in colorectal cancer. We previously reported that the solitary expression of either fascin-1 or MAP17 in colorectal cancer is associated with aggressive clinicopathological characteristics. The aim of the present study was to assess the clinical significance of the combined expression of both markers in colorectal cancer in terms of survival. A total of 111 patients with primary resectable colorectal cancer were examined for the expression of MAP17 and fascin-1 via immunohistochemistry. According to the cut-off points that were previously defined in our studies three groups of patients were compared; 1.) patients with combined low expression of fascin-1 and MAP17 (less than 10% staining within cancer cells for both markers) 2.) patients with combined high expression of fascin-1 and MAP17 (patients with fascin-1 expression more than 35% and expression of MAP17 more than 30% within cancer cells) 3.) all other patients were defined as displaying moderate expression of fascin-1 and MAP17. Results were correlated with clinicopathological characteristics as well as survival data. Progression-free survival (PFS) and overall survival (OS) were defined as the primary outcomes of this study. 33.3% of the patients displayed low combined fascin-1 and MAP 17 expression, 56.8% moderate expression, and 9.9% high expression. Combined expression of fascin-1 and MAP17 was associated with advanced T stage (p=0.020), the presence of lymph node (p < 0.001) and distant metastasis (p=0.001), higher grade of cellular differentiation (p=0.007), and the presence of vascular invasion (p=0.001). Interestingly, all patients with combined high expression of fascin-1 and MAP17 died within 46 months after surgery and only a 14.3% of the patients did not experience the event of recurrence or death in the first 30 months after surgery. On the contrary, patients with low expression of fascin-1 and MAP17 demonstrated an excellent 5-year progression-free survival and a 5-year overall survival up to 88.9%. Combined high expression of fascin-1 and MAP17 in patients with colorectal cancer identifies patients with aggressive tumor profiles. These two markers could be utilized in order to identify patients at risk for early death or as potential therapeutic targets.

Abstract Objective Colorectal cancer (CRC) remains the third most common cause of death from malignancies, while 30% of all these tumors develop in the rectum. The proximity of the rectum to vital structures, and in some cases the use of neoadjuvant treatment, make the surgical resection of this tumor a great challenge even for highly qualified surgeons. Understanding the mechanisms of rectal cancer (RC) development could lead to new concepts in the approach of diagnosis, prognosis, and eventually treatment of this disease. Despite the fact that TNM classification represents the gold standard tool for the staging of RC, a significant number of studies has recently focused on the association between the tumor microenvironment and RC. CD34 is a transmembrane phosphoglycoprotein expressed on human hematopoietic progenitor and vascular endothelial cells, as well in malignant tissues. It has also been shown to be involved in tumor invasion and angiogenesis. Because of the controversial data , we examined the expression of CD34 protein in RC specimens after stratifying the patients according to their UICC stage. Methods In our retrospective study, we included 364 patients with unselected, clinically annotated primary RC specimens. We analyzed a tissue microarray (TMA) of these specimens by immunohistochemistry (IHC) for the expression of CD34 protein by tumor cells. Results After stratifying the patients in nodal negative and positive groups, we found that the patients with Stage IIA tumors and high expression of CD34 protein had a favorable 5-year overall survival rate (53%; 95%CI = 40.0 – 65.1%) compared to tumors without expression of CD34 protein (26%; 95%CI = 10.7 – 44.6%, p = 0.003). Univariate and multivariate Hazard Cox regression survival analysis revealed that the combined the expression of CD34 protein was an independent, favorable, prognostic marker for overall survival in the stage IIA RC (HR = 0.39, 95%CI = 0.19 – 0.79; p = 0.009). Conclusion Our data show that the expression of CD34 protein represents an independent, favorable, prognostic condition in nodal negative stage IIA RC. Thereby, we provide novel insights into the prognostic role of the tumor microenvironment in RC that might help in the development of novel treatment modalities by its modification.

Abstract Objective Total thyroidectomy represents the gold standard surgical procedure for patients with malignant thyroid disease. Over the past decades, the total thyroidectomy gradually replaced the subtotal thyroidectomy for benign thyroid disorders as well. Postoperative hypocalcemia remains the most frequent complication. The close proximity of parathyroid glands to the thyroid capsule leads often to devascularization or adventitious removal of parathyroid tissue. Clinical symptoms like paresthesia, tingling, muscle cramps or seizures often occur. Combined measurement of intact parathyroid hormone (iPTH) and calcium after the operation are used worldwide to predict postoperative hypoparathyroidism. The purpose of this study was to find out the incidence of decreased iPTH at the end of surgery and its reliability in predicting hypocalcemia. Methods We performed a retrospective analysis of 534 patients who underwent total thyroidectomy at our institution between 2000 and 2019. Medical records were reviewed to analyze the patient characteristics, indication of the procedure, laboratory and histological results, postoperative management and complications. The iPTH was measured before and at the end of the surgery, while the calcium was measured at the first postoperative day. The iPTH assay at our hospital has a normal range between 15.0 and 80.0 pg/ml. Meanwhile hypocalcemia was defined as a calcium measurement < 2.2 mmol/l. Results The mean age of the patients was 55.34 years. The female to male ratio was 4.6:1. The mean preoperative iPTH of our cohort was 48.35 pg/ml, while the postoperative iPTH was 31.74 pg/ml, indicating a mean reduction of 35.75%. A total of 174 patients (32.6%) had a iPTH < 15.0 pg/ml at the end of the surgery, indicating a reduction of 75.6%. 22 of these 174 patients (12.6%) developed clinical symptoms of hypocalcemia. In contrast only 3 patients (0.08%) with normal iPTH developed symptoms. Whole parathyroid glands were identified in 95/534 (17.8%), whereas from the 174 patients with iPTH < 15.0 pg/ml, 56 (32.2%) had at least one parathyroid gland in the operative specimens. Conclusion Measurement of iPTH at the end of total thyroidectomy is a good predictor to detect patient who are at risk for developing symptomatic hypocalcemia and calcium substitution can be started at the same day. A normal iPTH almost excludes symptomatic hypocalcemia.

The benefit of a perianal block as an adjunct to general or regional anaesthesia is debated. This RCT aimed to compare pain at 24 h and up to 14 days after proctological surgery in patients with and without a perianal block. Between January 2018 and April 2019, patients were allocated to receive a perianal block with ropivacaine or placebo as an adjunct to anaesthesia. Patients, surgeons and assessors were blinded. The primary outcome was pain measured on a numerical rating scale (NRS) after 24 h. Secondary outcomes were need for rescue analgesia, and pain after 1, 2, 3, 6 and 12 h. The mean, rest and maximum NRS scores were measured for 14 days. A total of 138 patients were included, of whom 46 and 44 received general anaesthesia with or without ropivacaine respectively, and 23 and 25 received spinal anaesthesia with or without ropivacaine respectively ( P  = 0·858). The mean NRS score differed significantly at 24 h (mean(s.d.) 1·1(0·1) versus 2·3(0·2); P  < 0·001), but not at 1 h (1·4(0·2) versus 2·2(0·3); P  = 0·051). The NRS score was lower with use of ropivacaine at 2 h (1·0(0·2) versus 1·6(0·2); P  = 0·045), 3 h (0·9(0·2) versus 1·5(0·2); P  = 0·022), 6 h (1·1(0·2) versus 1·8(0·2); P  = 0·042) and 12 h (1·2(0·2) versus 1·8(0·2); P  = 0·034). The use of oral morphine equivalents was 10·2(1·4) and 16·6(2·5) mg with and without ropivacaine respectively ( P  = 0·028). The mean and maximum NRS scores within 14 days were lower when ropivacaine was used (95 per cent c.i. for difference 0·14 to 0·49 ( P  = 0·002) and 0·39 to 0·63 ( P  < 0·001) respectively). There was no injection-associated morbidity. Perianal block as an adjunct to general or regional anaesthesia should be recommended for proctological surgery. It yields a reduction in pain, a reduced need for opioids, and a faster recovery with minimal risk of adverse events. Registration number: NCT03405922 ( http://www.clinicaltrials.gov ).

Introduction: Colorectal cancer continues to be the third most common cancer and constitutes the second leading cause of cancer-associated death among adults in western societies. Despite the improvement of multimodality treatment with surgical resection and chemoradiation, disease recurrence either as local recurrence or metastatic disease represents a major cause of significant cancer-associated morbidity and mortality in colorectal cancer. L1CAM is a stem cell marker and a cell adhesion molecule that can be classified as a member of the immunoglobulin superfamily of cell adhesion molecules (IgCAM). Its aberrant expression in several different types of human solid tumors has been associated with aggressive tumor phenotypes. The aim of the present study was to assess the expression patterns of L1CAM and its clinical significance in colorectal cancer. Methods: A total of 109 patients with primary resectable colorectal cancer were examined for L1CAM expression via immunohistochemistry. Results were correlated with clinicopathological characteristics as well as survival data. Progression-free survival (PFS) and overall survival (OS) were defined as the primary outcomes of this study. Results: L1CAM displayed strong cytoplasmic expression in the colorectal cancer cells. Patients exhibiting high L1CAM expression were associated with advanced disease stage (P < .001), higher T stage (P = .040), the presence of lymph node (P < .001) and distant metastasis (P = .011). No correlations of L1CAM expression were demonstrated with the grade of tumor (P = .647), the presence of vascular (P = .360) or perineural invasion (P = .272) as wells as the presence of mucinous histologic subtype (P = .717). Kaplan-Meier curves revealed a significantly worse 3-year progression-free survival (29.7% vs 87.1%, P < .001) as well worse 5-year overall survival (39.9% vs 87.7%, P < .001) for patients displaying high L1CAM expression. Cox proportional hazard models demonstrated high L1CAM expression, independently of other clinicopathological characteristics, as a prognostic marker of progression-free survival (HR 0.187; 95%CI, 0.075-0.467; P < .001) and overall survival (HR 0.187; 95%CI, 0.049-0.483; P = .001). In the present study, patients with early stage cancer only and high L1CAM expression (Stage I and II according to UICC classification) presented as well significantly worse 3-year progression-free (42.9% vs 91.2%, P = .003) and 5-year overall survival (47.6% vs 90%, P = .008). Conclusion: High L1CAM expression in patients with colorectal cancer is associated with metastatic disease and dismal prognosis even in patients with early-stage disease. L1CAM could either represent a potential target for the development of a tumor profiling test in order to identify patients at high risk for disease recurrence or could be utilized as a target for immunotherapy.

OBJECTIVE:The ideal location of specimen extraction in laparoscopic-assisted colorectal surgery is still debatable. The aim of this study was to compare the incidence of incisional hernias and surgical site infections in patients undergoing elective laparoscopic resection for recurrent sigmoid diverticulitis by performing specimen extraction through left lower transverse incision or Pfannenstiel-Kerr incision.METHODS:A total of 269 patients operated between January 2014 and December 2017 were retrospectively screened for inclusion in the study. Patients with specimen extraction through left lower transverse incision (LLT) and patients with specimen extraction through Pfannenstiel-K incision (P-K) were matched in 1:1 proportion regarding age, sex, comorbidities, and previous abdominal surgery. The incidence of incisional hernias and surgical site infections were compared by using Fisher's exact test.RESULTS:After matching 77 patients in the LLT group and 77 patients in the P-K group, they were found to be homogenous regarding the above mentioned descriptive characteristics. No patients in the P-K group developed an incisional hernia compared with 10 patients (13%) in the LLT group (p = 0.001). All these patients required hernia repair with mesh augmentation. The rate of surgical site infections was 1/77 in the P-K group and 0/77 in the LLT group (p = 1.0). In the P-K group, a wound protector was used in 86% of patients whereas in the LLT group, 39% of the wounds were protected during specimen extraction (p < 0.0001).CONCLUSION:The Pfannenstiel-Kerr incision may be the preferred extraction site compared with the left lower transverse incision given the significant reduction of the risk of incisional hernias.