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Background: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. Methods: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. Results: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien–Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. Conclusion: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes. [ABSTRACT FROM AUTHOR]

Background: Concerns persist regarding the effectiveness of robotic proctectomy when compared with open proctectomy for locally advanced rectal cancer with a high risk of circumferential resection margin involvement., Objective: Comparison of surrogate cancer outcomes following robotic versus open proctectomy in this subpopulation., Design: Retrospective cohort study., Setting: Three academic hospitals (Mayo Clinic Arizona, Florida, and Rochester) through the Mayo Data Explorer platform., Patients: Patients at high risk of circumferential resection margin involvement were selected based on the magnetic resonance imaging-based definition from Mercury I and II trials., Primary and Secondary Outcome Measures: Rate of pathologic circumferential resection margin involvement (≤1 mm), mesorectal grading, rate of distal margin involvement., Results: Out of 413 patients, 125 (30%) underwent open and 288 (70%) robotic proctectomy. Open proctectomy was significantly associated with a greater proportion of cT4 tumors (39.3% vs. 24.8%, p = 0.021), multivisceral/concomitant resections (40.8% vs. 18.4%, p < 0.001) and less frequent total neoadjuvant therapy use (17.1% vs. 47.1%, p = 0.001). Robotic proctectomy was less commonly associated with pathologic circumferential resection margin involvement (7.3% vs. 17.6%, p = 0.002), including after adjustment for cT stage, neoadjuvant therapy, and multivisceral resection (OR 0.326, 95% CI, 0.157-0.670, p = 0.002). Propensity score-matching on 66 patients per group and related multivariable analysis no longer indicated any reduction of circumferential positive margin rate associated with robotic surgery (p = 0.86 and p = 0.18). Mesorectal grading was comparable (incomplete mesorectum in 6% RP patients vs. 11.8% OP patients, p = 0.327). All cases had negative distal resection margins., Limitation: Retrospective design., Conclusion: In patients with locally advanced rectal cancer at high risk of circumferential resection margin involvement, robotic proctectomy is an effective approach and could be pursued when technically possible as an alternative to open proctectomy. See Video Abstract., (Copyright © The ASCRS 2024.)

Background: Conventional neoadjuvant chemoradiotherapy (nCRT) yields a pathologic complete response (pCR) rate of 15%-30% for locally advanced rectal cancer (LARC). This study ventures to shift this paradigm by incorporating short-course nCRT with immunotherapy, specifically Envafolimab, to achieve improved treatment efficacy and possibly redefine the standard of care for LARC., Materials and Methods: The PRECAM study is a prospective, single-arm, phase 2 clinical trial for LARC in patients with microsatellite stable (MSS) tumors. Participants received short-course radiotherapy (25Gy/5f), followed by two cycles of CAPEOX chemotherapy and six weekly doses of Envafolimab, a PD-L1 antibody, before total mesorectal excision surgery. The primary endpoint was the pCR rate., Results: From April to December 2022, 34 patients were enrolled, of whom 32 completed the study, each diagnosed with an MSS rectal adenocarcinoma. All patients underwent preoperative CRT combined with Envafolimab. Remarkably, a pCR rate of 62.5% (20/32) was attained, and a significant pathologic response rate of 75% (24/32) was achieved. Additionally, 21 of 32 participants achieved a neoadjuvant rectal (NAR) score below 8, suggesting an effective treatment response. Common adverse events included tenesmus (78.1%), diarrhea (62.5%), and leukocyte decrease (40.6%). Two Grade 3 adverse events were noted, one related to liver function abnormality and the other to a decrease in platelet count. Surgical procedures were performed in all cases, with minor complications, including ileus, infections, and anastomotic leakage. As of this report, there have been no reported cases of recurrence or death during the follow-up period, ranging from 12 to 20 months., Conclusion: In LARC patients exhibiting MSS tumors, combining short-course nCRT with Envafolimab demonstrated favorable efficacy, leading to a significant pCR rate. Minor adverse effects and surgical complications were observed. These preliminary but promising results underscore the potential of this approach and call for further exploration and validation through a randomized controlled trial., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Ulcerative colitis, total colectomy and tofacitinib have all been associated with increased risk of venous thromboembolism., Objective: To determine if preoperative tofacitinib exposure increases venous thromboembolism or other postoperative complications among patients with ulcerative colitis undergoing subtotal colectomy, total colectomy or total proctocolectomy., Design: Retrospective, case-control study at a single institution., Settings: A tertiary referral center., Patients: Adult patients with ulcerative colitis undergoing subtotal colectomy, total colectomy or total proctocolectomy after 2018 who were taking tofacitinib within 30 days of surgery (n = 56) were compared to age and sex-matched patients with ulcerative colitis undergoing the same surgeries but who were not exposed to tofacitinib (n = 56)., Main Outcome Measure: The primary outcome was differences in the incidence of venous thromboembolism within 90 days of surgery based on tofacitinib exposure. Secondary outcomes were 90-day postoperative complications., Results: Groups were well matched for age (non-tofacitinib: mean 35.2 years [SD 12.0], tofacitinib: 35.9 [SD 12.1], p = 0.36) and sex (41% female in each group, p = 1.00). Medical characteristics were similar between groups except for biologic medication exposure 30 days before surgery (non-tofacitinib: 66%, tofacitinib: 36%, p = 0.004). Surgical characteristics did not differ between groups. Most patients were discharged on extended venous thromboembolism prophylaxis (non-tofacitinib: 80% and tofacitinib: 77%). Adjusted for biologic exposure, there were no statistically significant differences in venous thromboembolism (non-tofacitinib exposed: 14%, tofacitinib-exposed: 4%, p = 0.09) or other postoperative outcomes., Limitation: Retrospective, single institutional study., Conclusion: Among patients with ulcerative colitis undergoing total colectomy or proctocolectomy, exposure to tofacitinib was not associated with an increased risk of venous thromboembolism or other postoperative complications. See Video Abstract., Competing Interests: Financial Disclosures: The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Colon and Rectal Surgeons.)

Background: Ileal pouch-anal anastomosis has become the gold standard for treating ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn's colitis. Robotic surgery promises improved postoperative outcomes and decreased length of stay. However, few studies have evaluated the benefits of robotic ileal pouch-anal anastomosis compared to laparoscopy., Objective: To compare short-term 30-day postoperative outcomes of robotic versus laparoscopic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy., Design: Retrospective observational study from a single, high-volume center., Settings: Mayo Clinic, Rochester, MN (tertiary referral center for inflammatory bowel disease)., Patients: All adult patients undergoing minimally invasive proctectomy with ileal pouch-anal anastomosis and DLI between January 2015 and April 2023., Main Outcome Measures: Thirty-day complications, hospital length of stay, estimated blood loss, conversion rate, 30-day readmission, and 30-day reoperation., Results: Two hundred seventeen patients were included in the study; 107 underwent robotic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy, while 110 had laparoscopic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy. Operating time was significantly longer in the robotic group (263 ± 38 minutes versus 228 ± 75 minutes, p < 0.0001); estimated blood loss was lower in the robotic group (81.5 ± 77.7 ml vs. 126.8 ± 111.0 ml, p = 0.0006) as well as the number of conversions (0% versus 8.2%, p = 0.003). Patients in the robotic group received more intraoperative fluids (3099 ± 1140 ml versus 2472 ± 996 ml, p = 0.0001). However, there was no difference in length of stay, 30-day morbidity, 30-day readmission, 30-day reoperation, rate of diverting loop ileostomy closure at three months, and surgical ileal pouch-anal anastomosis complication rate after ileostomy closure., Limitations: Retrospective design, single-center study, potential bias due to the novelty of robotic approach, lack of long-term and quality-of-life outcomes., Conclusions: Robotic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy may offer advantages in terms of estimated blood loss and conversion rate, while maintaining the benefits of minimally invasive surgery. Further research is needed to evaluate long-term outcomes. See Video Abstract., (Copyright © The ASCRS 2024.)

Objective: To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer., Summary Background Data: Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data is crucial for continuous improvement. Previous studies suggest CUSUM charts hold promise in identifying performance trends and outliers., Methods: This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at two institutions. RA-CUSUM charts were generated for three outcomes: complications, operative time, and length of stay., Results: The overall RA-CUSUM curves for operative time and complications showed an initial learning phase followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while five minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins., Conclusions: The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality., Competing Interests: Conflicts of interest: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aims to assess the costs of a Same-Day Discharge Enhanced Recovery Pathway (SDD) for diverting loop ileostomy closure compared to a standard institutional enhanced recovery protocol (ERP)., Summary Background Data: Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020., Methods: A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing same-day discharge diverting loop ileostomy closure (SDD) from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient ERP. Patients were matched based on age, sex, ASA score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days post-discharge., Results: The SDD group (n=118) demonstrated a significant reduction in median index episode hospitalization and 30-day post-operative costs compared to the inpatient group (n=236), with savings of $4,827 per patient. Complication rates were similar, and so were readmission and reoperation rates., Conclusions: Implementation of the SDD for diverting loop ileostomy closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards same-day discharge protocols, offering economic benefits and potential improvements in healthcare resource utilization., Competing Interests: Conflicts of interest: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Using standard anterior approaches, consistent R0 resection of locally advanced primary and recurrent rectal and anal cancer involving the deep pelvic sidewall may be unattainable. Therefore, to improve R0 resection rates, we have used a posterior-first, then anterior 2-stage approach to resection of tumors in this location., Objective: To assess the R0 resection rate and surgical outcomes of the first 10 patients operated on using this approach., Design: We conducted a retrospective case series review of our prospectively maintained surgical pathology and tumor registries., Setting: This study was conducted at the Mayo Clinic in Rochester, Minnesota., Patients: Ten patients (6 female individuals, median age 53.5 years) with primary or recurrent anal or rectal cancer treated with a posterior-first, then anterior 2-stage approach were identified., Main Outcome Measures: The primary outcome measures were the R0 resection rate and surgical outcomes., Results: An R0 resection was achieved in all 10 patients. Nine patients developed 1 or more 30-day Clavien-Dindo grade III complications. Nine patients developed gluteal wound complications ranging from superficial wound dehiscence to flap necrosis. During the follow-up period, 4 patients were found to have metastatic disease and 1 patient had local re-recurrence., Limitations: Small cohort with heterogeneous tumors and a short follow-up duration., Conclusion: A posterior-first, then anterior 2-stage approach has allowed us to achieve consistent R0 resection margins in locally advanced primary and recurrent rectal and anal cancers involving the deep pelvic sidewall. Poor wound healing of the posterior gluteal incision is a common complication. See Video Abstract., Mejorando Las Tasas De Reseccin R Con Un Abordaje De Dos Etapas Primero Posterior Para La Reseccin En Bloque De Cnceres Anorrectales Primarios Y Recurrentes Localmente Avanzados Que Afectan La Pared Lateral Plvica Profunda: ANTECEDENTES:Utilizando abordajes anteriores estándares, la resección R0 consistente del cáncer de recto y ano primario y recurrente localmente avanzado involucrando la pared lateral pélvica profunda puede ser inalcanzable. Por lo tanto, para mejorar las tasas de resección R0, hemos empleado un abordaje de 2 etapas primero posterior y luego anterior para la resección de tumores en esta ubicación.OBJETIVO:Este estudio tuvo como objetivo evaluar la tasa de resección R0 y los resultados quirúrgicos de los primeros 10 pacientes operados con este abordaje.DISEÑO:Realizamos una revisión retrospectiva de series de casos de nuestros registros de patología quirúrgica y tumores mantenidos prospectivamente.AJUSTE:Este estudio se realizó en la Clínica Mayo en Rochester, Minnesota, EE. UU.PACIENTES:Se identificaron diez pacientes (6 mujeres, mediana de edad 53.5 años) con cáncer anal o rectal primario o recurrente tratados con un abordaje de dos etapas, primero posterior y luego anterior.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado primarias fueron la tasa de resección R0 y los resultados quirúrgicos.RESULTADOS:Se logró una resección R0 en los 10 pacientes. Nueve pacientes desarrollaron una o más complicaciones de grado III de Clavien-Dindo a los 30 días. Nueve pacientes desarrollaron complicaciones de la herida del glúteo que variaron desde dehiscencia superficial de la herida hasta necrosis del colgajo. Durante el período de seguimiento, se encontró que 4 pacientes tenían enfermedad metastásica y un paciente tuvo recurrencia local.LIMITACIONES:Cohorte pequeño con tumores heterogéneos y corta duración de seguimiento.CONCLUSIÓN:Un abordaje en 2 etapas, primero posterior y luego anterior, nos ha permitido lograr márgenes de resección R0 consistentes en cánceres de recto y anal primarios y recurrentes localmente avanzados que afectan la pared lateral pélvica profunda. La mala cicatrización de la incisión glútea posterior es una complicación común. (Traducción-Dr. Aurian Garcia Gonzalez)., (Copyright © The ASCRS 2023.)