Thomas Golda

Background: Bowel dysfunction and quality of life (QoL) are key determinants of long-term outcomes after treatment for localized rectal cancer (cT2–cT3a–b, N0, M0). Total mesorectal excision (TME) provides effective oncologic control but may cause substantial functional impairment. Organ-preserving strategies combining chemoradiotherapy with local excision may improve functional outcomes, yet long-term patient-reported data remain limited. Materials and Methods: TAUTEM is a multicenter, prospective, open-label, phase 3, randomized, noninferiority trial comparing chemoradiotherapy followed by transanal endoscopic microsurgery (CRT–TEM) with standard TME in patients with T2–T3ab, N0, M0 rectal cancer. Long-term bowel function was assessed using the Low Anterior Resection Syndrome (LARS) score ≥24 months after definitive treatment. Quality of life (QoL) was evaluated using the EORTC QLQ-C30, QLQ-CR38, and the Karnofsky Performance Status at baseline and after treatment. Analyses were conducted in the modified intention-to-treat and per-protocol populations. Results: Of 173 randomized patients, 162 were included in the modified intention-to-treat analysis (81 per group). Long-term LARS assessment was available for 96 of 102 eligible patients (94%) at a median follow-up of 87.5 months. Global QoL was higher after CRT–TEM than after TME (median 83.3 vs 66.7; P = 0.02). Permanent stoma rates were lower following CRT–TEM than after TME (7.4% vs 28.4%). Major LARS occurred less frequently after CRT–TEM than after TME (7.7% vs 36.4%; P = 0.001), with higher rates of no LARS (80.8% vs 47.7%; P = 0.001). Item-level outcomes (frequency, urgency, clustering, and flatus incontinence) consistently favored CRT–TEM. Conclusions: CRT–TEM was associated with substantially less long-term bowel dysfunction and superior QoL compared with TME, together with markedly fewer permanent stomas. These findings support organ-preserving strategies for selected patients with cT2–cT3a–b, N0, M0 rectal cancer.

Objective To assess the effect of high inferior mesenteric artery tie on defecatory, urinary, and sexual function after surgery for sigmoid colon cancer. Summary background data Performing a sigmoidectomy poses a notable risk of causing injury to the preaortic sympathetic nerves during the high ligation of the inferior mesenteric artery, as well as to the superior hypogastric plexus during dissection at the level of the sacral promontory. Postoperative defecatory and genitourinary dysfunction after sigmoid colon resection are often underestimated and underreported. Methods This study is a secondary research of a multicenter, single-blind, randomized clinical trial. The trial involved patients with sigmoid cancer who underwent either extended complete mesocolic excision (e-CME) or standard CME (s-CME). Patients completed questionnaires to assess defecatory, urinary, and sexual function before, 1 month after surgery, and 1 year after surgery. Multivariate analysis was conducted to identify factors associated with functional dysfunction. Results Seventy-nine patients completed functional assessments before and 1 year after surgery. One year after sigmoidectomy with a high tie of the inferior mesenteric artery, 15.2% of patients had minor low anterior resection syndrome (LARS) and 12.7% had major LARS; 22.2% of males and 29.4% of females had urinary dysfunction; and 43.8% of males and 27.3% of females had sexual dysfunction. After multivariate analysis, no significant associations were found between clinical and surgical factors and gastrointestinal or urinary dysfunction after 1 year of surgery. Age was identified as the only factor linked to sexual dysfunction in both sexes (women, β = − 0.54, p = 0.002; men β = − 0.38, p = 0.010). Regarding recovery outcomes, diabetes mellitus was identified as a contributing factor to suboptimal gastrointestinal recovery (p = 0.033) and urinary recovery in women (p = 0.039). Furthermore, the treatment arm was found to be significantly associated with the recovery of erectile function after 1 year of surgery (p = 0.046). Conclusions A high tie of the inferior mesenteric artery during sigmoidectomy is associated with a high incidence of defecatory and genitourinary dysfunction. Age was identified as a significant factor associated with sexual dysfunction 1 year after sigmoid colon resection in both sexes. Trial registration Clinical trials NCT03083951 Highlights • One year after high-tie sigmoidectomy, 27.9% of patients had LARS; 22.2% of the men and 29.4% of the women had urinary dysfunction; and 43.8% of the men and 27.3% of the women had sexual dysfunction. • e-CME is associated with a high rate of urinary dysfunction in men 1 year after surgery. However, after multivariate analysis, no association was found between e-CME and urinary dysfunction in men. • Age was correlated with the recovery of sexual function in both sexes 1 year after surgery. Furthermore, diabetes mellitus was identified as the factor associated with poorer recovery of urinary function in females.

Background Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. Methods Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). Results One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. Conclusion CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

Management of left colonic perforation in emergency depends largely upon the attending surgeon. The primary endpoint of this observational, retrospective study analyses surgical technique chosen by the colorectal specialized (CS) or general surgeon (GS) and changes over time. Interventions for left colonic perforation from 2004 to 2015 are grouped for CS or GS. Type of operation (Hartmann (HP), primary anastomosis (RPA) ±covering ileostomy (IL)), year, Peritonitis Severity Score (PSS), morbidity, mortality, anastomotic dehiscence and stoma closure were recorded. 190 patients were included. CS performed RPA ± IL in 83 pts (74.1%) and HP in 29 pts (25.9%) while GS performed RPA ± IL in 26 pts (33.3%) and HP in 52 pts (66.7%), (p < 0.001). CS performed over time more RPA with covering ileostomy to the detriment of HP. No differences were observed between the two surgeon-groups in terms of overall morbidity and mortality. Anastomotic dehiscence was higher among GS (20% vs 4.8%, p = 0.046). Mortality after HP overtrumped RPA (26.8% versus 11.0%, p = 0.009). Regression analysis showed that HP's probability increased 3.7 times by GS, 2.3 times by each PSS point and decreased 32.5% every forthcoming year (p < 0.001). A multinomial logistic model illustrates evolution of surgical management over time, CS leading towards extension of reconstructive techniques, subsequently adopted by GS. CS attempt bowel reconstruction in more patients than GS in left colonic perforation without differences in overall postoperative morbidity or mortality. CS introduced covering IL to further indicate primary anastomosis avoiding HP. GS stepwise adopted this management although results are improved by CS. These findings favor primary anastomosis with/without covering ileostomy in left colonic perforation in selected patients where PSS can be used as a tool to discriminate best candidates.

Aim: Immunosuppression is believed to worsen outcomes for patients who require surgery for perforated diverticulitis. The aim of this study was to compare surgical outcomes between immunocompromised and immunocompetent patients undergoing surgery for complicated diverticulitis.Method: All patients who underwent emergency surgery for complicated diverticulitis between 2004 and 2012 in a single unit were studied. Patients were classified as immunosuppressed (group I) or immunocompetent (group II). Operation type and postoperative morbidity and mortality were compared between groups. The impact of operating surgeons’ specialization and the Peritonitis Severity Score (PSS) were also evaluated to determine their impact on the restoration of gastrointestinal (GI) continuity.Results: One‐hundred and sixteen patients (mean age: 63.7 years), 41.4% women, were included. Fifty‐three (45.7%) patients were immunosuppressed (group I): 42 underwent Hartmann's procedure (HP) (79.2%), nine (17.0%) underwent resection and primary anastomosis (RPA) with ileostomy (IL) and two (3.8%) underwent RPA without IL. In group II, 15 HP (23.8%), nine RPA with IL (14.3%) and 39 RPA without IL (61.9%) were performed. Postoperative morbidity and mortality were 79.2% and 26.4%, respectively, in group I and 63.5% and 6.3%, respectively, in group II. The overall mean PSS was 9.5, with a mean PSS of 11.1 in group I and of 8.1 in group II. The decision to perform a primary anastomosis differed significantly between colorectal surgeons and general surgeons in the patients with a PSS of 9–10–11.Conclusion: In immunocompromised patients, RPA with IL can be a safe surgical option, whereas HP should be reserved for patients with a PSS of > 11. Colorectal surgical specialization is associated with higher rates of restoration of GI continuity in patients with perforated diverticulitis, especially in patients with an intermediate PSS score. Evaluation of each patient's PSS facilitates decision making in surgery for perforated diverticulitis.