LONG TERM OUTCOME OF ELECTIVE SURGERY

Transcription

1 LONG TERM OUTCOME OF ELECTIVE SURGERY Roberto Persiani Associate Professor Mini-invasive Oncological Surgery Unit Institute of Surgical Pathology (Dir. prof. D. D Ugo)

2 Dis Colon Rectum, March 2000 Dis Colon Rectum, July 2006

3 Elective surgery 2014 After one episode of complicated diverticulitis Case by case decision after uncomplicated diverticulitis by The American Society of Colon and Rectal Surgeons (ASCRS) Dis Colon Rectum, 2014

4 The value of surgery Multicentre retrospective and prospective study Resection after an episode of acute diverticulitis did not entirely protect against recurrence, although the risk was significantly lower than that after medical treatment Binda et al. Br J Surg 2012

5 The value of surgery 21 studies readmission to hospital for diverticular disease during follow up was greater in patients treated conservatively than in those having surgery (18.6% vs 6.1%, respectively) The recurrence of symptoms compatible with diverticular disease not leading to readmission was 43 86% in patients having medical treatment and 3 81% in those having surgery Peppas et al, J Gast Hepato 2007

6 DIRECT trial Dutch Diverticular Disease Collaborative Study Group Elective sigmoid resection vs conservative treatment Recurrence: Three or more recurrences within 2 yrs 214 pts. (18-75 yrs) and/or Chronic disease: Persistent abdominal complains after an episode of diverticulitis Primary endpoints HRQoL by GIQLI EQ-5D SF-36 VAS (pain) Secondary endpoints Mortality Morbidity Recurrences Perforations Fistula Abscess Stoma Periop. complications no technical aspects into consideration multicenter randomised clinical trial

7 The value of surgery Surgeons should reflect on their responsibilities Long-term function and Recurrence Morbidity and Mortality GI function Recurrent diverticulitis Defecatory disorder Urinary function Sexual function Incisional Hernias Small bowel obstruction

8 Technical aspects Level of Distal Resection Open vs Laparoscopic Surgery Level of Proximal Resection Mobilization of the Splenic Flexure Level of Vascular Ligation

9 Level of of distal distal resection resection - Long term results The risk of recurrent diverticulitis nearly doubled (12.5% versus 6.7%) if the distal resection margin included taenia coli indicating that sigmoid colon rather than true rectum was used in the anastomosis Benn et al. Am J Surg 1986 Recurring LPS vs Open vs No resections Recurring Thaler et al. urg Laparosc Endosc Percutan Tech, 2003

10 Level of distal resection

11 Technical aspects Level of Distal Resection Open vs Laparoscopic Surgery Level of Proximal Resection Mobilization of the Splenic Flexure Level of Vascular Ligation

12 Open vs LPS Long term results GIQLI score Cosmetics results p= ns p= Gervaz et al. Surg Endosc, 2011

13 Open vs LPS short term results Short term results Sigma Trial Short term complications LPS Open p Overall morbidity 22 (42.3%) 28 (53.8%) 0,239 Minor Complication Urinary tract infection Wound infection Pneumonia Other Combination 19 (36.5%) (38.5%) ,839 Major complication Anastomotic leak Bleeding Abscess Evisceration Bowel perforation Richter Hernia Myocardial infarction Pulmunary embolism 5 (9.6%) (25.0%) Death 0 1 (1.9%) Klarenbeek Ann Surg 2009

14 Technical aspects Level of Distal Resection Open vs Laparoscopic Surgery Level of Proximal Resection Mobilization of the Splenic Flexure Level of Vascular Ligation

15 Level of proximal of proximal resection resection - Long term results The American Society of Colon and Rectal Surgeons (ASCRS) Resect all colonic site(s) affected by previous episode(s) The proximal part of the anastomosis should be made in soft compliant colon Dis Colon Rectum, July 2006 The proximal resection should include the distal part of the descending colon if this site has been involved with acute diverticulitis Nearly a third (28%) of episode of acute diverticulitis are located in the distal descending colon. Hall JF e al. Dis Colon Rectum 2010 In 35% of patients who have a second episode of diverticulitis the recurrence involve another segment of the left colon. Gervaz et al. Colorectal Dis 2012

16 Level of proximal resection

17 Technical aspects Level of Distal Resection Open vs Laparoscopic Surgery Level of Proximal Resection Mobilization of the Splenic Flexure Level of Vascular Ligation

18 Splenic flexure mobilization It is closely related to the extension of the resection But The splenic flexure should be mobilized routinely for diverticular disease resections. This facilitates the anastomosis being made from soft, compliant bowel being brought down to the rectum. The Association of Coloproctology of Great Britain and Ireland Colorect Disease 2011

19 Technical aspects Level of Distal Resection Open vs Laparoscopic Surgery Level of Proximal Resection Mobilization of the Splenic Flexure Level of Vascular Ligation

20 Vascular approach Inferior Mesenteric Artery (IMA) approach Section of IMA High ligation Low ligation Preservation IMA With LCA preservation Without LCA preservation GI Function Anastomotic leak LCA: left colic artery

21 Long term results GI Function IMA-Section IMA-Preservation Colon denervated tract

22 Anastomotic leak Milsom et al, Ann Surg 2013

23 Anastomotic leak: anatomical basis 61% 32% 7% 39% Morton A. 1986

24 without preservation of left colic artery IMA preservation Advantages Better vascularization of the rectum Lower anastomotic leak with preservation of left colic artery Better vascularization of the rectum and colon (splenic angle): Lower anastomotic leak Better innervation of residual colon and rectum: Better post-operative functional results Less sexual morbidity

25 IMA preservation - Long term results 107 pts. IMA-P 54 pts. IMA-S 53 pts. Median follow-up of 6 months Defecatory disorder: Anorectal manometry Incontinence: Jorge-Wexner Incontinence Score (IS) Constipation: Agachan-Wexner Constipation Score (CS) QoL: Medical Outcomes Survey Short Form 36 (SF-36) Masoni et al Surg Endosc, 2013

26 IMA preservation - Long term results Postoperative Defecatory disorder Anorectal manometry Incontinence: Jorge-Wexner Incontinence Score (IS) IMAP (n 54) IMAS (n 53) p IMAP (n 54) IMAS (n 53) p Minor Incontinence Constipation Fragmented evacuations Alternating bowel function Solid Liquid Gas Wears pad Lifestyle alteration Patients with defecatory disorders Total Constipation: Agachan-Wexner Constipation Score (CS) QoL: Medical Outcomes Survey Short Form 36 IMAP (n 54) IMAS (n 53) P IMAP (n 54) IMAS (n 53) P Defecation frequency Incomplete defecation Straining at defecation Mean time spent to defecate Duration of constipation Unsuccessful defecation Assistance with defecation Abdominal pain Total Physical function Physical role Body pain General healt Vitality Social functioning Emotional role Mental heath Masoni et al Surg Endosc, 2013

27 Vascular approach

28 Vascular approach: left colic artery preservation LCA LCA IMA LCA SA IMA: Inferior mesenteric artery IMV: inferior mesenteric vein LCA: left colic artery SA: sigmoid artery

29 Conclusions We will have to wait for the results of the multicentre randomized clinical trial that will compare QoL and risk of recurrence after surgical and conservative treatment of patients with frequent recurrent and chronic disease. The time has come for rigorous analysis of the role of technical aspects of the surgical procedure

30 Conclusions Level of Distal Resection Including colorectal junction Open vs Laparoscopic Surgery Laparoscopic surgery Level of Proximal Resection Including the distal part of the descending colon Mobilization of the Splenic Flexure In order to decrease anastomotic tension Level of Vascular Ligation Preservation of IMA Preservation of LCA

31 Thanks Dr.ssa Valeria Fico Dr. Francesco Santullo General Surgery Residents Catholic University of Sacred Heart