RezumatSuprarenalectomia laparoscopicã a devenit gold standard pentru afecţiunile suprarenalei, de la incidentalom pânã la cancer. Suprarenalectomia parţialã este greu de acceptat din cauza dificultãţilor tehnice şi a riscurilor hemoragie, nefiind stabilit un consens. Pe de altã parte, în cazuri selecţionate de tumori benigne, suprarenalectomia poate fi excesivã, rezecţiile parţiale fiind perfect justificate cu risc hemoragic scãzut. Pentru tumori secretante de dimensiuni sub 3 cm, cu localizare anterioarã sau lateralã, suprarenalectomia parţialã poate fi indicatã. Reperele principale sunt reprezentate de identificarea adenomului, conservarea ţesutului glandular restant împreunã cu sursele vasculare şi disecţia precisã cu menţinerea spaţiului de clivaj între adenom şi restul parenchimului. Suprarenalectomia parţial laparoscopicã este fezabilã şi eficientã pentru tratamentul tumorilor de mici dimensiuni mai ales în localizãrile bilaterale. Aceste avantaje sunt contrabalansate de o tehnicã chirurgicalã mai dificilã.Cuvinte cheie: chirurgie laparoscopicã, suprarenalectomie, rezecţie suprarenalianã parţialã AbstractLaparoscopic adrenalectomy became the gold standard for adrenal disease, from incidentaloma to cancer. Partial adrenalectomy is difficult to accept due to its technical difficulties as well as hemorrhagic risk and a consensus has not been reached. On the other hand, in selected cases of benign adrenal tumors, adrenalectomy may be futile, partial resections being perfectly justified and with lower hemorrhagic risks. For functioning tumors smaller than 3 cm with an anterior or lateral location, partial adrenalectomy may be indicated. The key points reside in adenoma identification, preservation of the remaining glandular parenchyma and its blood supply with dissection in the space between the adenoma and the normal parenchyma. Laparoscopic partial adrenalectomy is feasible and effective for the treatment of benign tumors.

Introduction Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short‐term outcomes of TaTME, open, laparoscopic, and robotic TME internationally. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02–2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10–7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non‐transanal laparoscopic TME. However this association was lost in the mixed‐effects model controlling for patient and disease factors (OR 1.23, 0.77–1.97, P = 0.39 and OR 2.11, 0.79–5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55–4.77, P < 0.001) and male gender (OR 2.29, 1.52–3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%. Conclusion This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.

Introducere: Cancerul complicat de colon se prezintă cel mai adesea ca ocluzie intestinală şi necesită intervenţie chirurgicală în urgenţă. Majoritatea pacienţilor primesc diagnosticul când se prezintă pentru o complicaţie a bolii, moment în care boala este de obicei avansată. În timp ce supravieţuirea pacientului primează, intenţia curativă a rezecţiei conform principiilor chirurgiei oncologice poate cădea pe plan secund. Material şi metodă: Am analizat retrospectiv 68 de pacienţi consecutivi cu cancer de colon complicat care au suferit intervenţii chirurgicale în urgenţă în perioada Ianuarie 2017 -Septembrie 2018. Principiile rezecţiei oncologice au fost studiate în termeni de margini de rezecţie şi număr de limfonoduli rezecaţi, şi/sau rezecţii multiviscerale pentru a obţine margini negative. Cincizeci şi opt de pacienţi (85.3%) au fost diagnosticaţi cu ocluzie intestinală, perforaţie intestinală a fost observată în 8 cazuri (11.8%) în timp ce hemoragia digestivă inferioară a complicat 2 cazuri (2.9%). Douăzeci şi doi pacienţi au fost diagnosticaţi cu metastaze la distanţă iar per total 29 pacienţi (42,6%) au fost încadraţi în stadiul IV de boală. Margini circumferenţiale de rezecţie negative au fost obţinute în 91% din cazuri în timp ce margini longitudinale invadate au fost observate în 2 cazuri iar numărul mediu de limfonoduli rezecaţi a fost mai mare de 13,7. Durata medie de spitalizare a fost de 13.9 zile iar mortalitatea postoperatorie observată a fost de 19.1%. Rezultate: Rezultatele chirurgicale pentru cancer de colon complicat în departamentul nostru se încadrează în datele publicate în literatură. Concluzii: Principiile rezecţiei oncologice în ceea ce priveşte marginile de rezecţie şi numărul de limfonoduli rezecaţi pot fi respectate în contextul intervenţiei chirurgicale în urgenţă şi oferă şansa de vindecare acestor pacienţi cu boală avansată.Cuvinte cheie: cancer de colon complicat, rezecţie oncologică, chirurgie de urgenţă Abstract Introduction: Complicated colon cancer most frequently presents as obstruction and needs emergency surgery. Most of these patients receive their diagnosis when presenting for complicated disease and by that time the disease is usually advanced. While concerned first with the survival of the patient, the curative intent of the resection following the principles of oncologic resection may come in second place. Materials and methods: We retrospectively analyzed 68 consecutive patients with complicated colon cancer that suffered emergency surgery between January 2017 and September 2018. The principles of oncologic resection were analyzed in terms of resection margins and retrieved lymph nodes and/or multivisceral resections in order to achieve clear margins. Intestinal obstruction was observed in 58 patients (85.3%), perforation was found in 8 patients (11.8%) while lower gastrointestinal bleeding complicated 2 cases (2.9%). Twenty-two patients had distant metastases at presentation, and overall 29 patients (42,6%) had stage IV disease. Clear circumferential margins were a...

Introduction The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre‐operative imaging. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post‐treatment MRI restaging (yMRI) and final pathological staging. Results Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post‐treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T‐stage, N‐stage, or AJCC status were each graded as ‘fair’ only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively). Conclusion The reported pCR rate of 10% highlights the potential for non‐operative management in selected cases. The limited strength of agreement between basic conventional post‐chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials.

Background Laparoscopy has now been implemented as a standard of care for elective colonic resection around the world. During the adoption period, studies showed that conversion may be detrimental to patients, with poorer outcomes than both laparoscopic completed or planned open surgery. The primary aim of this study was to determine whether laparoscopic conversion was associated with a higher major complication rate than planned open surgery in contemporary, international practice. Methods Combined analysis of the European Society of Coloproctology 2017 and 2015 audits. Patients were included if they underwent elective resection of a colonic segment from the caecum to the rectosigmoid junction with primary anastomosis. The primary outcome measure was the 30‐day major complication rate, defined as Clavien‐Dindo grade III‐V. Results Of 3980 patients, 64% (2561/3980) underwent laparoscopic surgery and a laparoscopic conversion rate of 14% (359/2561). The major complication rate was highest after open surgery (laparoscopic 7.4%, converted 9.7%, open 11.6%, P < 0.001). After case mix adjustment in a multilevel model, only planned open (and not laparoscopic converted) surgery was associated with increased major complications in comparison to laparoscopic surgery (OR 1.64, 1.27–2.11, P < 0.001). Conclusions Appropriate laparoscopic conversion should not be considered a treatment failure in modern practice. Conversion does not appear to place patients at increased risk of complications vs planned open surgery, supporting broadening of selection criteria for attempted laparoscopy in elective colonic resection.