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Background: Although minimally invasive rectal surgery (MIRS) for cancer provides better recovery for similar oncologic outcomes over open approach, conversion is still required in 10% and its impact on short-term and long-term outcomes remains unclear. The aim of our study was to evaluate the impact of conversion on postoperative and oncologic outcomes in patients undergoing MIRS for cancer. Methods: From June 2011 to March 2020, we reviewed 257 minimally invasive rectal resections for cancer recorded in a prospectively maintained database, with 192 robotic and 65 laparoscopic approaches. Patients who required conversion to open (Conversion group) were compared to those who did not have conversion (No conversion group) in terms of short-term, histologic, and oncologic outcomes. Univariate and multivariate analyses of the risk factors for postoperative morbidity were performed. Results: Eighteen patients (7%) required conversion. The conversion rate was significantly higher in the laparoscopic approach than in the robotic approach (16.9% vs 3.6%, p< 0.01). Among the 4 reactive conversions, 3 (75%) were required during robotic resections. Patients in the Conversion group had a higher morbidity rate (83.3% vs 43.1%, p= 0.01) and more severe complications (38.9%, vs 18.8%, p= 0.041). Male sex [HR = 2.46, 95%CI (1.41–4.26)], total mesorectal excision [HR = 2.89, 95%CI (1.57–5.320)], and conversion (HR = 4.87, 95%CI [1.34–17.73]) were independently associated with a higher risk of overall 30-day morbidity. R1 resections were more frequent in the Conversion group (22.2% vs 5.4%, p= 0.023) without differences in the overall (82.7 ± 7.0 months vs 79.4 ± 3.3 months, p= 0.448) and disease-free survivals (49.0 ± 8.6 months vs 70.2 ± 4.1 months, p= 0.362). Conclusion: Conversion to laparotomy during MIRS for cancer was associated with poorer postoperative results without impairing oncologic outcomes. The high frequency of reactive conversion due to intraoperative complications in robotic resections confirmed that MIRS for cancer is a technically challenging procedure.

Background: Surgery demonstration (SD) is considered to be a mainstay of surgical education, but controversy exists concerning the patient’s safety. Indeed, the presence of visiting surgeons is a source of distraction and may have an impact on surgeon’s performance. This study’s objective was to evaluate possible differences in outcomes between robotic sphincter-saving rectal cancer surgery (RRCS) performed during routine surgical practice versus in the presence of visiting surgeons in the operating room (OR) with direct access to the surgeon. Methods: Retrospective case-matched studies were conducted from a prospectively collected database. 114 patients (38 with the presence of visiting surgeons) who underwent RRCS between January 2013 and September 2018 were included. Patients were matched in a 1:2 basis after propensity score analysis using five criteria: gender, body mass index, preoperative chemoradiation, type of mesorectum excision, and synchronous liver metastasis. Results: There was no difference between the two groups with regard to mean operating time, estimated blood loss, conversion, and hospital stay. Also, overall (44% vs. 40%; P= 0.6), major morbidity (26% vs. 19%; P= 0.5), and unplanned reoperation (17% vs. 15%; P= 1.0) rates were not statistically different. No difference was noted with regard to the quality of mesorectum excision, or positive rate of circumferential and distal longitudinal resection margins. The mean number of harvested lymph nodes (17 vs. 14.5; P= 0.04) was lower in the SD group and the number of patients with < 12 harvested lymph nodes (31% vs. 16%; P= 0.09) was greater after SD although it did not reach statistical significance. No differences were observed in disease-free or overall survival. Conclusions: The presence of visiting surgeons in the OR seems not to interfere in the quality of rectal resection and does not compromise patient’s short-term outcome and survival. However, mild differences in the extent of lymphadenectomy were observed and the surgeons performing SD may be aware of this.

Pancreatic cancer is a major cause of cancer-associated mortality, with a dismal overall prognosis that has remained almost unchanged for many decades. Pancreatic cancer has few prevalent genetic mutations. Available data on dMMR pancreatic cancer is limited and heterogeneous with regard to its prevalence and prognostic implications. Discordant results are mainly due to differences in detection methods and sample sizes. Interest in dMMR is growing since initial reports on immune checkpoint inhibition therapy for pancreatic cancer has shown it to be effective, generating impressive and durable responses. However, it has been accompanied by several questions regarding the appropriate screening, detection tools, patient selection, timing and modality of testing. Herein, we provide an extensive literature review and outline recommendations for testing.

Perineal hernia (PH) is formed by the protrusion of intra-abdominal viscera through a defect in the pelvic floor. This is a rare complication after conventional abdominoperineal resection, pelvic exanteration, proctectomy, and other pelvic procedures. The purpose of the present paper is to report 4 cases of PH after laparoscopic abdominoperineal resection for rectal cancer and to review literature data about the incidence, predisposing factors, and treatment of this challenging problem. When added to other 3 cases previously reported in the Brazilian series of laparoscopic surgery, this group of 7 cases comprises a PH incidence of 3.5% after rectal resection procedures. Surgical treatment is indicated only in symptomatic patients with no signs of cancer recurrence. Proposed methods of surgical repair include abdominal, perineal, or combined approaches to the hernia in association with the use of autologous tissues or prosthetic meshes. Preventive measures are represented by closure of the pelvic peritoneum whenever possible, primary perineal suture and wound care to avoid infection.