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Lauscher J, Beyer K, Hellinger A, Croner RS, Ridwelski K, Krautz C, Lim C, Coplan PM, Kurepkat M, Ribaric G. Impact of a digital surgical workflow including Digital Device Briefing Tool on morbidity and mortality in a patient population undergoing primary stapled colorectal anastomosis for benign or malignant colorectal disease: protocol for a multicentre prospective cohort study. BMJ Open 2023; 13:e070053. [PMID: 36972968 PMCID: PMC10069574 DOI: 10.1136/bmjopen-2022-070053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION With growing emphasis on surgical safety, it appears fundamental to assess the safety of colorectal resection involving primary stapled anastomosis. Surgical stapling devices can considerably foster patient safety in colorectal surgery, but their misuse or malfunction encompass a unique risk of postoperative complications. The Digital Device Briefing Tool (DDBT) is a digital cognitive aid developed to enhance safe use of the Ethicon circular stapling device during colorectal resection. The purpose of this study is to evaluate how a digital operative workflow, including DDBT, compared with routine surgical care, affects morbidity and mortality in patients undergoing left-sided colorectal resection with primary stapled colorectal anastomosis for colorectal cancer or benign disease. METHODS AND ANALYSIS A multicentre, prospective cohort study will be conducted at five certified academic colorectal centres in Germany. It compares a non-digital with a Johnson & Johnson digital solution (Surgical Process Institute Deutschland (SPI))-guided operative workflow in patients undergoing left hemicolectomy, sigmoidectomy, anterior rectal resection and Hartmann reversal procedure. The sample size is set at 528 cases in total, divided into 3 groups (a non-digital and two SPI-guided workflow cohorts, with and without DDBT) in a ratio of 1:1:1, with 176 patients each. The primary endpoint is a composite outcome comprising the overall rate of surgical complications, including death, during hospitalisation and within the first 30 days after colorectal resection. Secondary endpoints include operating time, length of hospital stay and 30-day hospital readmission rate. ETHICS AND DISSEMINATION This study will be performed in line with the Declaration of Helsinki. The ethics committee of the Charité-University Medicine Berlin, Germany, approved the study (No: 22-0277-EA2/060/22). Study Investigators will obtain written informed consent from each patient before a patient may participate in this study. The study results will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER DRKS00029682.
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Willis MA, Keller PS, Sommer N, Koch F, Ritz JP, Beyer K, Reißfelder C, Hardt J, Herold A, Buhr HJ, Emmanuel K, Kalff JC, Vilz TO. Adherence to fast track measures in colorectal surgery-a survey among German and Austrian surgeons. Int J Colorectal Dis 2023; 38:80. [PMID: 36964828 PMCID: PMC10039823 DOI: 10.1007/s00384-023-04379-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE The effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement. METHODS Twenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel. RESULTS While some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains). CONCLUSION The implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.
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Liu XR, Liu XY, Zhang B, Liu F, Li ZW, Yuan C, Wei ZQ, Peng D. Enhanced recovery after colorectal surgery is a safe and effective pathway for older patients: a pooling up analysis. Int J Colorectal Dis 2023; 38:81. [PMID: 36964841 DOI: 10.1007/s00384-023-04377-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE The current study aimed to explore the efficacy and safety of Enhanced Recovery after surgery (ERAS) in older patients undergoing colorectal surgery. METHODS Three databases including PubMed, Embase, Medline, and the Cochrane Library were used for searching eligible studies on Jun 8th,2022. To evaluate the effect of ERAS, we focused on the short-term outcomes including postoperative complications and recovery. Subgroup analysis was also conducted for patients undergoing colorectal cancer (CRC) surgery. All the data processing and analyses were carried out by Stata (V.16.0) software. RESULTS Finally, there were fourteen studies involving 5961 patients enrolled in this study. As for surgical outcomes, we found that the older group had more overall complications (OR = 1.41, I2 = 36.59%, 95% CI = 1.20 to 1.65, P = 0.00), more obstruction (OR = 1.462, I2 = 0.00%, 95% CI = 1.037 to 2.061, P = 0.0304), more respiratory complications (OR = 1.721, I2 = 0.00%, 95% CI = 1.177 to 2.515, P = 0.0051), more cardiovascular complications (OR = 3.361, I2 = 57.72%, 95% CI = 1.072 to 10.542, P = 0.0377), more urinary complications (OR = 1.639, I2 = 37.63%, 95% CI = 1.168 to 2.299, P = 0.0043), less readmission (OR = 0.662, I2 = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), higher mortality (OR = 0.662, I2 = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), and longer overall survival (OS) (HR = 1.21, I2 = 0.00%, 95% CI = 0.566 to 1.859, P = 0.0002)). Subgroup analysis also found that older CRC patients had a higher risk of overall complications (OR = 1.37, I2 = 37.51%, 95% CI = 1.06 to 1.78, P < 0.05). CONCLUSION Although ERAS could accelerate postoperative recovery and reduce postoperative complications, older patients who received ERAS still had higher complication incidence than younger patients. Although the proportion of re-hospitalizations was lower and the OS was better, doctors could not rely too much on ERAS. More measures were needed to improve the outcomes of colorectal surgery in older patients.
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SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease. Surg Endosc 2023; 37:2538-2547. [PMID: 36922428 DOI: 10.1007/s00464-023-09965-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease. METHODS A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions. RESULTS The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection). CONCLUSIONS The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.
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Fan Y, Zhu X, Xu C, Ding C, Hu J, Hong Q, Wang J. Neoadjuvant Arterial Embolization Chemotherapy Combined PD-1 Inhibitor for Locally Advanced Rectal Cancer (NECI Study): a protocol for a phase II study. BMJ Open 2023; 13:e069401. [PMID: 36914193 PMCID: PMC10016271 DOI: 10.1136/bmjopen-2022-069401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION The NICHE trial showed remarkable results of neoadjuvant immunotherapy in colorectal cancer patients with mismatch repair (MMR) deficiency (dMMR). However, rectal cancer patients with dMMR accounted for only 10% of case. The therapeutic effect is unsatisfactory in MMR-proficient patients. Oxaliplatin has been demonstrated to induce immunogenic cell death (ICD), which may improve the therapeutic effect of programmed cell death 1 blockade; however, a maximum tolerated dose is required to induce ICD. Arterial embolisation chemotherapy provides drugs locally and can easily reach the maximum tolerated dose, which could be a significant method for delivering chemotherapeutic agents. Therefore, we designed a multicenter, prospective, single-arm, phase II study. METHODS AND ANALYSIS First, recruited patients will receive neoadjuvant arterial embolisation chemotherapy (NAEC) with oxaliplatin 85 mg/m2 and 3 mg/m2. After 2 days, three cycles of immunotherapy with intravenous tislelizumab (200 mg/body, day 1) will be initiated at an interval of 3 weeks. From the second cycle of immunotherapy, the XELOX regimen will be added. 3 weeks after neoadjuvant therapy finished, the operation will be initiated. Neoadjuvant Arterial Embolization Chemotherapy Combined PD-1 Inhibitor for Locally Advanced Rectal Cancer (NECI) Study combined arterial embolisation chemotherapy, immunotherapy and systemic chemotherapy. Based on this combination therapy, the maximum tolerated dose could easily be reached, and ICD could be induced by oxaliplatin easily. To our knowledge, the NECI Study is the first multicenter, prospective, single-arm, phase II clinical trial to assess the efficacy and safety of NAEC combined with tislelizumab and systemic chemotherapy in locally advanced rectal cancer. This study is expected to provide a new neoadjuvant therapeutic regimen for locally advanced rectal cancer. ETHICS AND DISSEMINATION The Human Research Ethics Committee of the Fourth Affiliated Hospital of Zhejiang University School of Medicine approved this study protocol. The results will be published in peer-reviewed journals and presented at appropriate conferences. TRIAL REGISTRATION NUMBER NCT05420584.
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Nann S, Rana A, Karatassas A, Eteuati J, Tonkin D, McDonald C. Robot-assisted general surgery is safe during the learning curve: a 5-year Australian experience. J Robot Surg 2023:10.1007/s11701-023-01560-8. [PMID: 36897528 PMCID: PMC10374810 DOI: 10.1007/s11701-023-01560-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
Robot-assisted general surgery has become increasingly common in the Australian public sector since 2003. It provides significant technical advantages compared to laparoscopic surgery. Currently, it is estimated that the learning curve for surgeons starting off with robotic surgery is complete after 15 cases. This is a retrospective case series, following the progress of four surgeons with minimal robotic experience over 5 years. Patients undergoing colorectal procedures and hernia repairs were included. 303 robotic cases were included in this study, 193 colorectal surgeries and 110 hernia repairs. 20.2% of colorectal patients experienced an adverse event and 10.0% of hernia patients had a complication. The learning curve was correlated to the average docking time, and it was found that this was complete after 2 years, or after a minimum of 12 to 15 cases. Patient length of stay decreases as surgeon experience increases. Robotic surgery is a safe approach to colorectal surgery and hernia repairs with some potential benefits in terms of patient outcomes as surgeon experience increases.
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Tueme-de la Peña D, Salgado-Gamboa EA, Ortiz de Elguea-Lizárraga JI, Zambrano Lara M, Rangel-Ríos HA, Chapa-Lobo AF, Salgado-Cruz LE. Indocyanine green fluorescence angiography in colorectal surgery: A retrospective case-control analysis in Mexico. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023:S2255-534X(23)00022-1. [PMID: 36890063 DOI: 10.1016/j.rgmxen.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 01/09/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION AND AIMS An anastomotic leak is one of the most dreaded complications in colorectal surgery because it increases postoperative morbidity and mortality. The aim of the present study was to identify whether indocyanine green fluorescence angiography (ICGFA) reduced the anastomotic dehiscence rate in colorectal surgery. MATERIAL AND METHODS A retrospective study on patients that underwent colorectal surgery with colonic resection or low anterior resection and primary anastomosis, within the time frame of January 2019 and September 2021, was conducted. The patients were divided into the case group, in which ICGFA was performed for the intraoperative evaluation of blood perfusion at the anastomosis site, and the control group, in which ICGFA was not utilized. RESULTS A total of 168 medical records were reviewed, resulting in 83 cases and 85 controls. Inadequate perfusion that required changing the surgical site of the anastomosis was identified in 4.8% of the case group (n = 4). A trend toward reducing the leak rate with ICGFA was identified (6% [n = 5] in the cases vs 7.1% in the controls [n = 6] [p = 0.999]). The patients that underwent anastomosis site change due to inadequate perfusion had a 0% leak rate. CONCLUSIONS ICGFA as a method to evaluate intraoperative blood perfusion showed a trend toward reducing the incidence of anastomotic leak in colorectal surgery.
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Wyse R, Smith S, Zucca A, Fakes K, Mansfield E, Johnston SA, Robinson S, Oldmeadow C, Reeves P, Carey ML, Norton G, Sanson-Fisher RW. Effectiveness and cost-effectiveness of a digital health intervention to support patients with colorectal cancer prepare for and recover from surgery: study protocol of the RecoverEsupport randomised controlled trial. BMJ Open 2023; 13:e067150. [PMID: 36878662 PMCID: PMC9990701 DOI: 10.1136/bmjopen-2022-067150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Surgery is the most common treatment for colorectal cancer (CRC) and can cause relative long average length of stay (LOS) and high risks of unplanned readmissions and complications. Enhanced Recovery After Surgery (ERAS) pathways can reduce the LOS and postsurgical complications. Digital health interventions provide a flexible and low-cost way of supporting patients to achieve this. This protocol describes a trial aiming to evaluate the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention in decreasing the hospital LOS in patients undergoing CRC surgery. METHODS AND ANALYSIS The two-arm randomised controlled trial will assess the effectiveness and cost-effectiveness of the RecoverEsupport digital health intervention compared with usual care (control) in patients with CRC. The intervention consists of a website and a series of automatic prompts and alerts to support patients to adhere to the patient-led ERAS recommendations. The primary trial outcome is the length of hospital stay. Secondary outcomes include days alive and out of hospital; emergency department presentations; quality of life; patient knowledge and behaviours related to the ERAS recommendations; health service utilisation; and intervention acceptability and use. ETHICS AND DISSEMINATION The trial has been approved by the Hunter New England Research Ethics Committee (2019/ETH00869) and the University of Newcastle Ethics Committee (H-2015-0364). Trial findings will be disseminated via peer-reviewed publications and conference presentations. If the intervention is effective, the research team will facilitate its adoption within the Local Health District for widespread adaptation and implementation. TRIAL REGISTRATION NUMBER ACTRN12621001533886.
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Horisberger K, Mann C, Lang H. Current Surgical Concepts in Lynch Syndrome and Familial Adenomatous Polyposis. Visc Med 2023; 39:1-9. [PMID: 37009233 PMCID: PMC10051043 DOI: 10.1159/000530030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
Background Approximately 5% of colorectal cancers (CRCs) are associated with hereditary cancer syndromes. The natural history of these syndromes differs from sporadic cancers, and due to their increased risk of metachronous carcinomas, surgical approaches also differ. This review focuses on the current recommendations for surgical treatment and what evidence has led to these recommendations in the most clinically relevant hereditary CRC syndromes: Lynch syndrome (LS) and (attenuated) familial adenomatous polyposis (FAP). Summary LS has no common phenotype and is caused by individual germline variants in one of the mismatch repair genes (MLH1, MSH2, MSH6, or PMS2). Because each gene is associated with a different risk of metachronous cancer, guidelines now differentiate between genes in their recommendations for oncology interventions. Classical and attenuated FAP are caused by germline mutations in the APC gene and have a characteristic phenotype. Although correlations exist between phenotype and genotype, the indication for surgery is predominantly based on clinical manifestation rather than specific gene mutations. Key Message Currently, the recommendation on the two diseases tends to go in opposite directions: while some forms of FAP may require less extensive surgery, in some LS patients, more sophisticated knowledge of metachronous carcinoma risk leads to more extensive surgery.
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Levy BE, Castle JT, Ebbitt LM, Kennon C, McAtee E, Davenport DL, Evers BM, Bhakta A. Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use. J Surg Res 2023; 283:296-304. [PMID: 36423479 DOI: 10.1016/j.jss.2022.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.
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Hany TS, Jadav AM, Parkin E, McAleer J, Barrow P, Bhowmick AK. The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study. J Surg Res 2023; 283:172-178. [PMID: 36410233 DOI: 10.1016/j.jss.2022.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/07/2022] [Accepted: 10/19/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position. METHODS The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure. RESULTS Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures. CONCLUSIONS This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.
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Simillis C, Charalambides M, Mavrou A, Afxentiou T, Powar MP, Wheeler J, Davies RJ, Fearnhead NS. Operative blood loss adversely affects short and long-term outcomes after colorectal cancer surgery: results of a systematic review and meta-analysis. Tech Coloproctol 2023; 27:189-208. [PMID: 36138307 DOI: 10.1007/s10151-022-02701-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery. METHODS A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion. RESULTS Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02). CONCLUSIONS Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject.
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Johnson CE, Brooke BS. Preoperative functional performance is the best predictor for loss of independence after major surgery among older adults. Evid Based Nurs 2023; 27:ebnurs-2022-103654. [PMID: 36854609 DOI: 10.1136/ebnurs-2022-103654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/02/2023]
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Berta E, Srovnal J, Dytrych P, Bruthans J, Ulrichova J, Prasil P, Vecera L, Gabrhelik T, Tolmaci B, Dusa J, Maca J, Mazancova M, Haiduk F, Kutej M, Ihnat P, Michalek P, Hajduch M. Influence of opioid analgesia type on circulating tumor cells in open colorectal cancer surgery (POACC-1): study protocol for a prospective randomized multicenter controlled trial. BMC Anesthesiol 2023; 23:64. [PMID: 36855089 PMCID: PMC9972763 DOI: 10.1186/s12871-023-02007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/02/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Opioids and epidural analgesia are a mainstay of perioperative analgesia but their influence on cancer recurrence remains unclear. Based on retrospective data, we found that cancer recurrence following colorectal cancer surgery correlates with the number of circulating tumor cells (CTCs) in the early postoperative period. Also, morphine- but not piritramide-based postoperative analgesia increases the presence of CTCs and shortens cancer-specific survival. The influence of epidural analgesia on CTCs has not been studied yet. METHODS We intend to enroll 120 patients in four centers in this prospective randomized controlled trial. The study protocol has been approved by Ethics Committees in all participating centers. Patients undergoing radical open colorectal cancer surgery are randomized into epidural, morphine, and piritramide groups for perioperative analgesia. The primary outcome is the difference in the number of CTCs in the peripheral blood before surgery, on the second postoperative day, and 2-4 weeks after surgery. The number of CTCs is measured using molecular biology methods. Perioperative care is standardized, and relevant data is recorded. A secondary outcome, if feasible, would be the expression and activity of various receptor subtypes in cancer tissue. We intend to perform a 5-year follow-up with regard to metastasis development. DISCUSSION The mode of perioperative analgesia favorably affecting cancer recurrence would decrease morbidity/mortality. To identify such techniques, trials with long-term follow-up periods seem suboptimal. Given complex oncological therapeutic strategies, such trials likely disable the separation of perioperative analgesia effects from other factors. We believe that early postoperative CTCs presence/dynamics may serve as a sensitive marker of various perioperative interventions´ influences on cancer recurrence. Importantly, it is unbiased to the influence of long-term factors and minimally invasive. Analysis of opioid/cannabinoid receptor subtypes in cancer tissue would improve understanding of underlying mechanisms and promote personalization of treatment. We are not aware of any similar ongoing studies. TRIAL REGISTRATION NUMBER NCT03700411, registration date: October 3, 2018. STUDY STATUS recruiting.
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O'Brien L, Morarasu S, Morarasu BC, Neary PC, Musina AM, Velenciuc N, Roata CE, Dimofte MG, Lunca S, Raimondo D, Seracchioli R, Casadio P, Clancy C. Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes. Int J Colorectal Dis 2023; 38:55. [PMID: 36847868 DOI: 10.1007/s00384-023-04352-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection. METHODS The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes. RESULTS Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable. CONCLUSION Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.
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Yamamoto R, Yoshida K, Ando M, Toyoda Y, Tanaka A, Kato K, Yamaguchi R. Retroperitoneal and Mediastinal Emphysema after Sigmoid Colon Resection. Case Rep Gastroenterol 2023; 17:137-142. [PMID: 36843657 PMCID: PMC9950965 DOI: 10.1159/000529282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Abstract
Retroperitoneal and mediastinal emphysema after colon resection is extremely rare, especially in the absence of anastomotic leakage. The feasibility and safety of conservative treatment for this complication are unknown. We report a patient who underwent open sigmoid colon resection for colon cancer and developed retroperitoneal and mediastinal emphysema that was not caused by anastomotic leakage. Retroperitoneal and mediastinal emphysema occurred as a result of diverticular perforation. We were able to treat this patient successfully with conservative management.
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Patient experiences of left-sided colorectal resection by robotic, conventional laparoscopic and open approaches: a qualitative study. Tech Coloproctol 2023:10.1007/s10151-023-02764-8. [PMID: 36790541 DOI: 10.1007/s10151-023-02764-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Robotic surgery (RS) is increasingly employed in colorectal surgical practice, widening the range of surgical techniques offered to patients. We investigated the perceptions of patients with colorectal cancer in relation to RS, open surgery (OS) and conventional laparoscopic surgery (CLS), to identify ideas or assumptions which, in the context of shared surgeon-patient decision-making, may affect the resultant choice of surgical technique. We also investigated salient factors affecting patients' perioperative experience, including those of RS patients, to guide improvements in care and preoperative patient preparation. METHODS This study was conducted on patients who underwent resection of left-sided colorectal cancer at a large UK teaching hospital from November 2020 to July 2021. Purposive sampling was used to ensure a roughly equal proportion of patients who underwent RS, CLS and OS. The patients included in the study participated in semi-structured interviews six weeks postoperatively. The interview schedule allowed discussion around patients' experience of their surgery and postoperative recovery, and their perceptions of surgical techniques. Interview transcripts were coded manually using inductive thematic analysis, and analyst triangulation was employed to refine coding schemes and ensure reliability of emerging themes. RESULTS Twenty-seven patients were recruited to the study; RS n = 9 (median age 69 [range 60-80] years); CLS n = 10 (median age 72 [range 32-82] years; OS n = 8 (median age 71 [range 60-75] years). Patients understood the technological benefits of RS but were concerned by a risk of technological failure causing patient harm. OS was understood to be associated with more pain and longer recovery than RS or CLS. Patients perceived CLS to be more technically challenging compared with OS. Less pain and smaller wounds than expected were significant positive factors in the experience of RS and CLS patients specifically. Complications and emotional impact were significant factors in the experience of all groups, for which many patients felt underprepared. CONCLUSIONS Patients generally have a positive view of RS and technical innovation in surgery. Concerns mostly centred around failure of technology. Many patients felt unprepared for significant factors in their perioperative experience. Surgeons and healthcare providers should be prepared to address patients' perceptions and expectations of colorectal surgery preoperatively.
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Vuhahula EAM, Yahaya J, Morgan ED, Othieno E, Mollel E, Mremi A. Frequency and distribution of ABO and Rh blood group systems among blood donors at the Northern Zone Blood Transfusion Center in Kilimanjaro, Tanzania: a retrospective cross-sectional study. BMJ Open 2023; 13:e068984. [PMID: 36787973 PMCID: PMC9930552 DOI: 10.1136/bmjopen-2022-068984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
OBJECTIVES ABO and Rh blood group systems are the major factors affecting the blood transfusion safety. The frequency and distribution of these blood group systems vary worldwide. We aimed to determine the frequency and distribution of ABO and Rh blood group systems among first-time blood donors at the Northern Zone Blood Transfusion Center in Kilimanjaro, Tanzania. DESIGN Cross-sectional descriptive population-based study. SETTING Data on ABO and Rh blood group systems were obtained and analysed from the Northern Zone Blood Transfusion Center among first-time blood donors. PARTICIPANTS There were 65 535 first-time blood donors aged 15-55 years who donated at the Northern Zone Blood Transfusion Center from January 2017 to December 2019. OUTCOME MEASURES The percentage of ABO and Rh blood group systems among different categories of blood donors was calculated. RESULTS Retrospective data from Blood Establishment Computer System of 65 535 first-time blood donors were analysed in the present study. The mean age of the blood donors was 30.6±11.2 years (range: 15-55 years). The vast majority of the blood donors 84.2% (n=55 210) were men. Also, the majority 69.6% (n=45 595) were aged ≥35 years. Blood group O was the most common blood group which was found in over half 52.4% (n=34 333) of the blood donors and majority 95.3% (n=62 461) of the donors were Rh positive. Moreover, the majority 78.3% (n=51 336) were voluntary donors and the remaining 21.7% (n=14 199) were replacement donors. CONCLUSION Majority of the donors had blood group O and also the vast majority of the donors were Rh positive. Considering the large size of our study population, this has provided a more comprehensive information regarding the frequency and patterns of ABO and Rh blood group systems in Tanzania. The observed association of blood group A with one of the regions from which donors were coming from, is intriguing and further studies may confirm possible related genetic evolution.
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Mueller T, Dimpel R, Kehl V, Friess H, Reim D. Surgical site infection prevention in abdominal surgery: is intraoperative wound irrigation with antiseptics effective? Protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e066140. [PMID: 36787980 PMCID: PMC9930547 DOI: 10.1136/bmjopen-2022-066140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Surgical site infection (SSI) after laparotomy still represents the most frequent postoperative complicationin abdominal surgery. The effectiveness of reducing SSI rates by intra-operative irrigation of the incisional wound with antiseptic solutions or saline has been much debated, and recommendations on its use are divergent. Therefore, we aim to conduct a systematic review and meta-analysis, focusing specifically on procedures by laparotomy and considering recent evidence only. METHODS AND ANALYSIS The systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. On 1 July 2022, PubMed/MEDLINE, Cochrane, Central Register of Controlled Trials and EMBASE were searched for the following predefined terms: (Surgical site infection) AND ((irrigation) OR (wound irrigation) OR (lavage)) AND ((abdominal surgery) OR (laparotomy). The search was limited to peer-revied publications, dating after 1 January 2000 in English or German language. Systematic reviews and meta-analyses were included for reference screening. Case reports, case series, non-systematic reviews and studies without follow-up information were excluded. The primary outcome is the rate of postoperative SSI after abdominal surgery by laparotomy. Meta-analysis is pooled using the Mantel-Haenszel method for random effects. The risk of bias in randomised studies will be assessed using the Cochrane developed RoB 2-tool, and the ROBINS-I tool for non-randomised studies. Completion of the analysis and publication is planned in March 2023. ETHICS AND DISSEMINATION Ethical approval is not necessary for this study, as no new data will be collected. The results of the final study will be published in a peer-reviewed open-access journal. PROSPERO REGISTRATION NUMBER CRD42022321458.
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Kehlet H. Perioperative systematic reviews and meta-analyses-time for design improvement. Int J Colorectal Dis 2023; 38:38. [PMID: 36781497 DOI: 10.1007/s00384-023-04337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/15/2023]
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de Carvalho MDSR, Pellino G, Pereira AMG, Bray-Beraldo F, Lopes RGC, Di Saverio S. Prevalence of urinary dysfunction after minimally invasive surgery for deep rectosigmoid endometriosis. Langenbecks Arch Surg 2023; 408:83. [PMID: 36773124 DOI: 10.1007/s00423-023-02831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE This study aimed to assess the prevalence and progression of lower urinary tract symptoms following laparoscopic surgery for deep-infiltrating endometriosis of the rectosigmoid and identify preoperative factors associated with worse postoperative outcomes. METHODS Prospective, observational study. SETTINGS single-center, referral hospital for endometriosis. Patients undergoing laparoscopic surgery for deep-infiltrating endometriosis of the rectosigmoid colon between October 2016 and October 2018. MAIN OUTCOME MEASURES urinary function was assessed with the validated Portuguese language version of the International Prostate Symptom Score, which is also used in women. The score was collected before and after surgery. The Wilcoxon signed-rank test was used to compare pre and postoperative scores and the chi-square test compared symptoms categorized by severity. RESULTS Fifty-three patients were assessed and 44 were included. Concerning urinary symptoms after surgery, the irritative symptoms prevailed over the obstructive ones. Additionally, 58.8% and 54.5% of the women reported moderate or severe symptoms at pre and postoperative, respectively. In at least one questionnaire category, the postoperative questionnaire scores increased in ten (22.7%) participants. A statistically significant difference was found comparing the changes from absent/mild to moderate/severe IPSS categories (P = 0.039). No significant changes were identified in any of the International Prostate Symptom Score pre and postoperatively (P = 0.876). CONCLUSIONS There was a high prevalence of pre and postoperative urinary symptoms. Patients with preoperative moderate/severe International Prostate Symptom Score are at risk of persisting urinary dysfunction after surgery for rectosigmoid deep endometriosis.
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McKechnie T, Elder G, Ichhpuniani S, Chen AT, Logie K, Doumouras A, Hong D, Benko R, Eskicioglu C. Perioperative intravenous dexamethasone for patients undergoing colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:32. [PMID: 36759373 DOI: 10.1007/s00384-023-04327-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE Dexamethasone is a glucocorticoid that is often administered intraoperatively as prophylaxis for postoperative nausea and vomiting (PONV). Several randomized controlled trials (RCTs) have examined its use in colorectal surgery. This systematic review aims to assess the postoperative impacts of dexamethasone use in colorectal surgery. METHODS MEDLINE, Embase, and CENTRAL were searched from database inception to January 2023. Articles were included if they compared perioperative intravenous dexamethasone to a control group in patients undergoing elective colorectal surgery in terms of postoperative morbidity. The primary outcomes were prolonged postoperative ileus (PPOI) and PONV. Secondary outcomes included postoperative infectious morbidity and return of bowel function. A pair-wise meta-analysis and GRADE assessment of the quality of evidence were performed. RESULTS After reviewing 3476 relevant citations, seven articles (five RCTs, two retrospective cohorts) met the inclusion criteria. Overall, 1568 patients received perioperative dexamethasone and 1459 patients received a control. Patients receiving perioperative dexamethasone experienced significantly less PPOI based on moderate-quality evidence (three studies, OR 0.46, 95%CI 0.28-0.74, p < 0.01). Time to first flatus was significantly reduced with intravenous dexamethasone. There was no difference between groups in terms of PONV (four studies, OR 0.90, 95%CI 0.64-1.27, p = 0.55), postoperative morbidity (OR 0.93, 95%CI 0.63-1.39, p = 0.74), or rate of postoperative infectious complications (seven studies, OR 0.74, 95%CI 0.55-1.01, p = 0.06). CONCLUSION This review presents moderate-quality evidence that perioperative intravenous dexamethasone may reduce PPOI and enhance the return of bowel function following elective colorectal surgery. There was no significant observed effect on PONV or postoperative infectious complications.
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Valibouze C, Speca S, Dubuquoy C, Mourey F, M'Ba L, Schneider L, Titecat M, Foligné B, Genin M, Neut C, Zerbib P, Desreumaux P. Saccharomyces cerevisiae prevents postoperative recurrence of Crohn's disease modeled by ileocecal resection in HLA-B27 transgenic rats. World J Gastroenterol 2023; 29:851-866. [PMID: 36816618 PMCID: PMC9932430 DOI: 10.3748/wjg.v29.i5.851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/16/2022] [Accepted: 12/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Postoperative recurrence (POR) after ileocecal resection (ICR) affects most Crohn's disease patients within 3-5 years after surgery. Adherent-invasive Escherichia coli (AIEC) typified by the LF82 strain are pathobionts that are frequently detected in POR of Crohn's disease and have a potential role in the early stages of the disease pathogenesis. Saccharomyces cerevisiae CNCM I-3856 is a probiotic yeast reported to inhibit AIEC adhesion to intestinal epithelial cells and to favor their elimination from the gut.
AIM To evaluate the efficacy of CNCM I-3856 in preventing POR induced by LF82 in an HLA-B27 transgenic (TgB27) rat model.
METHODS Sixty-four rats [strain F344, 38 TgB27, 26 control non-Tg (nTg)] underwent an ICR at the 12th wk (W12) of life and were sacrificed at the 18th wk (W18) of life. TgB27 rats were challenged daily with oral administration of LF82 (109 colony forming units (CFUs)/day (d), n = 8), PBS (n = 5), CNCM I-3856 (109 CFUs/d, n = 7) or a combination of LF82 and CNCM I-3856 (n = 18). nTg rats receiving LF82 (n = 5), PBS (n = 5), CNCM I-3856 (n = 7) or CNCM I-3856 and LF82 (n = 9) under the same conditions were used as controls. POR was analyzed using macroscopic (from 0 to 4) and histologic (from 0 to 6) scores. Luminal LF82 quantifications were performed weekly for each animal. Adherent LF82 and inflammatory/regulatory cytokines were quantified in biopsies at W12 and W18. Data are expressed as the median with the interquartile range.
RESULTS nTg animals did not develop POR. A total of 7/8 (87%) of the TgB27 rats receiving LF82 alone had POR (macroscopic score ≥ 2), which was significantly prevented by CNCM I-3856 administration [6/18 (33%) TgB27 rats, P = 0.01]. Macroscopic lesions were located 2 cm above the anastomosis in the TgB27 rats receiving LF82 alone and consisted of ulcerations with a score of 3.5 (2 - 4). Seven out of 18 TgB27 rats (39%) receiving CNCM I-3856 and LF82 had no macroscopic lesions. Compared to untreated TgB27 animals receiving LF82 alone, coadministration of CNCM I-3856 and LF82 significantly reduced the macroscopic [3.5 (2 - 4) vs 1 (0 - 3), P = 0.002] and histological lesions by more than 50% [4.5 (3.3 - 5.8) vs 2 (1.3 - 3), P = 0.003]. The levels of adherent LF82 were correlated with anastomotic macroscopic scores in TgB27 rats (r = 0.49, P = 0.006), with a higher risk of POR in animals having high levels of luminal LF82 (71.4% vs 25%, P = 0.02). Administration of CNCM I-3856 significantly reduced the levels of luminal and adherent LF82, increased the production of interleukin (IL)-10 and decreased the production of IL-23 and IL-17 in TgB27 rats.
CONCLUSION In a reliable model of POR induced by LF82 in TgB27 rats, CNCM I-3856 prevents macroscopic POR by decreasing LF82 infection and gut inflammation.
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Khomvilai S, Pattarajierapan S. Comparison of long-term outcomes of colonic stenting as a "bridge to surgery" and emergency surgery in patients with left-sided malignant colonic obstruction. Ann Coloproctol 2023; 39:17-26. [PMID: 34324803 PMCID: PMC10009074 DOI: 10.3393/ac.2021.00227.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Long-term oncologic outcomes of colonic stenting as a "bridge to surgery" in patients with left-sided malignant colonic obstruction (LMCO) are unclear. This study was performed to compare long-term outcomes of self-expandable metal stent (SEMS) insertion as a bridge to surgery and emergency surgery in patients with acute LMCO. METHODS This retrospective cohort study included patients with acute LMCO who underwent SEMS insertion as a bridge to surgery or emergency surgery. The primary outcomes were 5-year disease-free survival (DFS), overall survival (OS), and recurrence rate. Survival outcomes were determined using the Kaplan-Meier method and compared using log-rank tests. RESULTS There was a trend of worsening 5-year OS rate in the SEMS group compared with emergency surgery group (45% vs. 57%, P=0.07). In stage-wise subgroup analyses, a trend of deteriorating 5-year OS rate in the SEMS group with stage III (43% vs. 59%, P=0.06) was observed. The 5-year DFS and recurrence rate were not different between groups. The overall median follow-up time was 58 months. On multivariate analysis, age of ≥65 years and American Joint Committee on Cancer stage of ≥III, and synchronous metastasis were significant poor prognostic factors for OS (hazard ratio [HR], 1.709; 95% confidence interval [CI], 1.007-2.900; P=0.05/HR, 1.988; 95% CI, 1.038-3.809; P=0.04/HR, 2.146; 95% CI, 1.191-3.866; P=0.01; respectively). CONCLUSION SEMS as a bridge to surgery may have adverse oncologic outcomes. Patients in the SEMS group had a trend of worsening 5-year OS rate without higher recurrence.
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Sica GS, Vinci D, Siragusa L, Sensi B, Guida AM, Bellato V, García-Granero Á, Pellino G. Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review. Surg Endosc 2023; 37:846-861. [PMID: 36097099 PMCID: PMC9944740 DOI: 10.1007/s00464-022-09548-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation. METHODS PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques. RESULTS Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique. CONCLUSIONS The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.
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Van Hoof S, Sels T, Patteet E, Hendrickx T, Van den Broeck S, Hubens G, Komen N. Functional outcome after Hartmann's reversal surgery using LARS, COREFO & QoL scores. Am J Surg 2023; 225:341-346. [PMID: 36116971 DOI: 10.1016/j.amjsurg.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Functional complaints after colorectal surgery have a profound effect on quality of life (QoL). Our goal was to investigate the prevalence of functional complaints and quality of life after Hartmann's reversal surgery. METHOD A cross-sectional study was performed where one hundred nineteen patients were included. All patients underwent Hartmann's reversal procedure between 2007 and 2019. All patients were asked to complete 3 validated questionnaires related to bowel function in benign and colorectal cancer surgery as well as general QoL. RESULTS The response rate was 67%. Among responders, 32.8% reported LARS-like symptoms whereas 25% had significant COREFO Scores (>15). Higher LARS and COREFO scores were significantly associated with worse global QoL and several QoL domain scores (p < 0.05). CONCLUSION This study highlights the prevalence of bowel dysfunction after Hartmann's reversal surgery. Patients undergoing this procedure show similar functional complaints compared to those in literature who had a resection without colostomy.
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Ore AS, Vigna C, Fabrizio A, Cataldo TE, Messaris E, Crowell K. Are IBD Patients Underscored when Determining Postoperative VTE Risk? J Gastrointest Surg 2023; 27:347-353. [PMID: 36394799 DOI: 10.1007/s11605-022-05525-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism (VTE) following colorectal surgery and there is currently no consensus on post-surgical VTE prevention or specific VTE risk assessment tools. We sought to evaluate VTE risk after colorectal surgery and determine if known risk factors used in risk assessment tools adequate correlate with VTE risk in IBD patients. METHODS Retrospective cohort study using the National Surgical Quality Improvement Project (NSQIP) Participant User File from 2010 to 2018. RESULTS A total of 27,679 patients were included; 19,015 (68.7%) had Crohn's disease (CD) and 8664 (31.3%) ulcerative colitis (UC). Of these, 16,749 (60.5%) underwent abdominopelvic procedures, 10,178 (36.8%) complex pelvic procedures, and 752 (2.7%) small bowel operations. The overall VTE rate was 2.3%. The VTE rate in patients with CD and UC was 1.8% and 3.6% (p < 0.001) respectively. Overall median time to VTE was 9 days after surgery. VTE rate was highest in patients who underwent complex pelvic procedures (3.6%; 361/10,178). A risk score was calculated using 16/40 available variables from the Caprini VTE Risk Assessment tool; risk score ranged from 3 to 12 points. Most patients that developed a VTE had a score between 3 and 5 points (75.6%), and only 24.5% had a score of 6 or higher. Patients with higher risk scores did not have a higher VTE incidence. CONCLUSION Post-surgical VTE rates are high in IBD patients. Over half of the events occurred following discharge and in patients with an apparent low-risk score. Additional studies are warranted to define a recommended postoperative VTE prophylaxis regimen for patients with IBD.
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Celentano V, Adamina M, Spinelli A, Fleshner P, Pellino G, Mineccia M, Selvaggi F, Svrcek M, Tozer P, Espin-Basany E, Hancock L, Faiz O, Coffey CJ, Sampietro G. SupportiNg operAtive Photographic documentation in ileocolonic CROHN's disease surgery: The SNAPCROHN study. Colorectal Dis 2023; 25:282-288. [PMID: 36109836 DOI: 10.1111/codi.16342] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/14/2022] [Accepted: 09/06/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are reported variations in the intraoperative management of Crohn's disease. This consensus statement aimed to develop a standardised protocol for photographic documentation of intraoperative findings and critical procedural steps in ileocolonic Crohn's disease surgery. METHODS Colorectal surgeons with a specialist interest in minimally invasive surgery and inflammatory bowel disease were invited as committee members to develop a survey on the use of photo-documentation in Crohn's disease surgery. A 15 item survey was developed on ethical considerations and applications of photo-documentation in audit and quality control, research, and training. RESULTS There was strong agreement on the potential application of intraoperative photo-documentation in Crohn's disease for training, research, quality control and tertiary referrals. Reviewers agreed that intraoperative staging required photo-documentation of strictures, skip lesions, perforations, fat wrapping and mesenteric disease. The necessary steps to be photo-documented were very specific to Crohn's disease surgery, such as views of anastomosis and strictureplasties, and extent of resection(s). CONCLUSIONS Our consensus statement identified several items for appropriate intraoperative photo-documentation in Crohn's disease surgery, to be used as an adjunct to accurate annotation of intraoperative findings and procedures.
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Chen X, Leng W, Zhou Y, Yu Y, Meng W, Cao P, Wang Z, Qiu M. Pathological response and safety of FOLFOXIRI for neoadjuvant treatment of high-risk relapsed locally advanced colon cancer: study protocol for a single-arm, open-label phase II trial. BMJ Open 2023; 13:e062659. [PMID: 36720570 PMCID: PMC9890744 DOI: 10.1136/bmjopen-2022-062659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Neoadjuvant chemotherapy (NAC) has been demonstrated effective in several tumours, but its benefit has not yet been elucidated in colorectal cancer, especially locally advanced colorectal cancer (LACRC). METHODS AND ANALYSIS This is a single-arm, open-label, prospective phase II exploratory clinical trial. Patients with LACRC will receive four cycles of NAC with 5-fluorouracil, oxaliplatin and irinotecan (FOLFOXIRI), followed by operation and then adjuvant chemotherapy with capecitabine and oxaliplatin for two to five cycles or single-agent capecitabine for five cycles, or observation. The primary endpoint is the rate of tumour regression grade (TRG) 0-2 in the resected tumour tissue, which is evaluated by experienced pathologists according to the Ryan R TRG grading system. Secondary endpoints include objective response rate, pathologic complete response, microscopically complete resection rate, progression-free survival, distant metastasis-free survival, overall survival, toxicity and compliance to study treatment, molecular markers, quality of life to study treatment and the number of patients with 30-day postoperative mortality. The objective of this study is to analyse the efficacy and safety of FOLFOXIRI as the NAC regimen in patients with LACRC and to identify a promising treatment strategy in this setting. ETHICS AND DISSEMINATION Written informed consent will be required from and provided by all patients enrolled. The study protocol has been approved by the independent ethics committee of West China Hospital, Sichuan University (approval number: 2021403). This study will demonstrate the potential benefit of NAC with the FOLFOXIRI regimen. Results will be shared with policymakers and the academic community to promote the clinical management of colon cancer. TRIAL REGISTRATION NUMBER NCT05018182.
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Garcia-Granero A, Jerí Mc-Farlane S, Gamundí Cuesta M, González-Argente FX. Application of 3D-reconstruction and artificial intelligence for complete mesocolic excision and D3 lymphadenectomy in colon cancer. Cir Esp 2023; 101:359-368. [PMID: 36709852 DOI: 10.1016/j.cireng.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/29/2022] [Indexed: 01/28/2023]
Abstract
Mathematical algorithms 3D-reconstruction techniques and artificial intelligence are a current line of innovation in colorectal surgical oncology. The objective of this study is to show the initial experience of a 3D image processing and reconstruction system to perform complete mesocolic excision and D3-lymphadenectomy in colon cancer. It is applied to a splenic flexure neoplasm and in a right colon cancer with suspected retroperitoneal infiltration. 3D image processing and reconstruction was employed to delimit 10 cm proximal and distal intestinal margins to the tumor and define its corresponding vascularization. In right colon cancer it showed position and exact dimensions of D3-lymphadenectomy area and possible retroperitoneal fascia infiltration. 3D image processing and reconstruction allows to obtain valuable information from computerized tomography scan. It could be employed during surgical strategy planification to improve oncological results and reduce intraoperative complications.
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Weber MC, Berlet M, Stoess C, Reischl S, Wilhelm D, Friess H, Neumann PA. A nationwide population-based study on the clinical and economic burden of anastomotic leakage in colorectal surgery. Langenbecks Arch Surg 2023; 408:55. [PMID: 36683099 PMCID: PMC9868041 DOI: 10.1007/s00423-023-02809-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/11/2023] [Indexed: 01/24/2023]
Abstract
AIM Anastomotic leakage (AL) is one of the most dreaded complications in colorectal surgery. In 2013, the International Classification of Diseases code K91.83 for AL was introduced in Germany, allowing nationwide analysis of AL rates and associated parameters. The aim of this population-based study was to investigate the current incidence, risk factors, mortality, clinical management, and associated costs of AL in colorectal surgery. METHODS A data query was performed based on diagnosis-related group data of all hospital cases of inpatients undergoing colon or sphincter-preserving rectal resections between 2013 and 2018 in Germany. RESULTS A total number of 690,690 inpatient cases were included in this study. AL rates were 6.7% for colon resections and 9.2% for rectal resections in 2018. Regarding the treatment of AL, the application of endoluminal vacuum therapy increased during the studied period, while rates of relaparotomy, abdominal vacuum therapy, and terminal enterostomy remained stable. AL was associated with significantly increased in-house mortality (7.11% vs. 20.11% for colon resections and 3.52% vs. 11.33% for rectal resections in 2018) and higher socioeconomic costs (mean hospital reimbursement volume per case: 14,877€ (no AL) vs. 37,521€ (AL) for colon resections and 14,602€ (no AL) vs. 30,606€ (AL) for rectal resections in 2018). CONCLUSIONS During the studied time period, AL rates did not decrease, and associated mortality remained at a high level. Our study provides updated population-based data on the clinical and economic burden of AL in Germany. Focused research in the field of AL is still urgently necessary to develop targeted strategies to prevent AL, improve patient care, and decrease socioeconomic costs.
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Chen SY, Radomski SN, Stem M, Papanikolaou A, Gabre-Kidan A, Atallah C, Efron JE, Safar B. Colorectal Surgery Outcomes in the United States During the COVID-19 Pandemic. J Surg Res 2023; 287:95-106. [PMID: 36893610 PMCID: PMC9868386 DOI: 10.1016/j.jss.2022.12.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/02/2022] [Accepted: 12/25/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic. METHODS Adult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proctectomy procedure-targeted files were included. The prepandemic time period was defined from April 1, 2019 to December 31, 2019. The pandemic time period was defined from April 1, 2020 to December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression. RESULTS Among 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery prepandemic and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% prepandemic versus 15.2% pandemic, P < 0.001), with less laparoscopic cases (54.0% versus 51.0%, P < 0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity and in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic. CONCLUSIONS Differences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and providers on timely medical workup and management, and optimizing discharge coordination pathways.
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Rectal stimulation with prebiotics and probiotics before ileostomy reversal: a study protocol for a randomized controlled trial. Trials 2023; 24:31. [PMID: 36647079 PMCID: PMC9843864 DOI: 10.1186/s13063-023-07065-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/02/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Ileostomy closure is associated with a high rate of postoperative morbidity, and adynamic ileus is the most common complication, with an incidence of up to 32%. This complication is associated with delayed initiation of oral diet intake, abdominal distention, prolonged hospital stay, and more significant patient discomfort. The present study aims to evaluate the rectal stimulus with prebiotics and probiotics before ileostomy reversal. METHODS This is a protocol study for an open-label randomized controlled clinical trial. Ethical approval was received (CAAE: 56551722.6.0000.0071). The following criteria will be used for inclusion: adult patients with rectal cancer stages cT3/4Nx or cTxN+ that underwent loop protection ileostomy, patients treated with neoadjuvant chemoradiotherapy, and patients who underwent laparoscopic or robotic total mesorectal excision. Patients will be randomized to one of two groups. The intervention group (with rectal stimulus): the patients will apply 500 ml of saline solution with 6 g of Simbioflora® rectally, once a day, for 15 days before ileostomy closure. The control group (without rectal stimulation): the patients will close the ileostomy with no previous rectal stimulus. The primary outcomes will be the adynamic ileus (need for postoperative nasogastric tube insertion; nausea/vomiting; or intolerance to oral feedings within the first 72 h) and intestinal transit (time to first evacuation/flatus). RESULTS The patient's enrollment starts in January 2023. We expect to finish in July 2025. DISCUSSION The findings of this randomized clinical study may have important implications for managing patients undergoing ileostomy reversal. TRIAL REGISTRATION This study is registered in the Brazilian Trial Registry (ReBEC) under RBR-366n64w. Registration date: 19/07/2022.
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Iwamoto M, Makutani Y, Yane Y, Ushijima H, Yoshioka Y, Wada T, Daito K, Tokoro T, Chiba Y, Ueda K, Kawamura J. The usefulness of the endoscopic surgical skill qualification system in laparoscopic right hemicolectomy: a single-center, retrospective analysis with propensity score matching. Langenbecks Arch Surg 2023; 408:33. [PMID: 36645519 DOI: 10.1007/s00423-023-02810-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/11/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy. METHODS A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM). RESULTS After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174 min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0 ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9 days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394). CONCLUSION Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.
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Aguilar-Frasco JL, Moctezuma-Velázquez P, Rodríguez-Quintero JH, Castro E, Armillas-Canseco F, Hernández-Gaytán CA, Pastor-Sifuentes FU, Moctezuma-Velázquez C. Preoperative frailty assessment in older patients with colorectal cancer: use of clinical and radiological tool. Langenbecks Arch Surg 2023; 408:19. [PMID: 36627461 DOI: 10.1007/s00423-023-02754-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 10/31/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE The Memorial Sloan Kattering Frailty Index (MSK-FI) and the Skeletal Muscle Index (SMI) have recently gained attention as markers of frailty and decreased physiologic reserve, and are promising as predictors of adverse postoperative outcomes in patients undergoing oncologic surgery. The objective of this study was to establish the prognostic accuracy of these indexes in a cohort of patients with colorectal cancer subjected to surgical intervention. METHODS We performed an observational study including all patients older than 60 years, subjected to colorectal cancer surgery between January 2010 and May 2020, and stratified our cohort based on the presence of frailty, as defined by MSK-FI ≥ 3. Computed tomography was used to calculate SMI, using a standardized institutional protocol. A multivariable analysis was used to study the association between these novel indexes with adverse postoperative outcomes in our cohort. RESULTS A total of 216 patients were included. Among these, 56 (26%) qualified as frail and 132 (62%) had a low SMI. On multivariable analysis (adjusted by patient and intraoperative characteristics), frailty was associated with increased risk of having a major postoperative complication (OR 29.78, 95%CI 10.36-85.71) and increased admission to the intensive care unit (OR 4.99, 95%CI 1.55-16.06), while both frailty and low SMI were associated with prolonged length of stay (OR 11.22, 95%CI 8.91-13.53 and OR 0.14, 95% CI 0.06-0.20, respectively). CONCLUSION MSK-FI ≥ 3 and low SMI are associated with adverse postoperative outcomes in elderly patients undergoing colorectal cancer surgery. Implementing this practical tool in routine clinical practice, may help identify patients that would benefit from surgical prehabilitation and preoperative optimization to improve outcomes.
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Coxon-Meggy AH, Vogel I, White J, Croft J, Corrigan N, Meggy A, Stocken DD, Keller D, Hompes R, Knowles CH, Quyn A, Cornish J. Pathway Of Low Anterior Resection syndrome relief after Surgery (POLARiS) feasibility trial protocol: a multicentre, feasibility cohort study with embedded randomised control trial to compare sacral neuromodulation and transanal irrigation to optimised conservative management in the management of major low anterior resection syndrome following rectal cancer treatment. BMJ Open 2023; 13:e064248. [PMID: 36627161 PMCID: PMC9835955 DOI: 10.1136/bmjopen-2022-064248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Rectal cancer is common with a 60% 5-year survival rate. Treatment usually involves surgery with or without neoadjuvant chemoradiotherapy or adjuvant chemotherapy. Sphincter saving curative treatment can result in debilitating changes to bowel function known as low anterior resection syndrome (LARS). There are currently no clear guidelines on the management of LARS with only limited evidence for different treatment modalities. METHODS AND ANALYSIS Patients who have undergone an anterior resection for rectal cancer in the last 10 years will be approached for the study. The feasibility trial will take place in four centres with a 9-month recruitment window and 12 months follow-up period. The primary objective is to assess the feasibility of recruitment to the POLARiS trial which will be achieved through assessment of recruitment, retainment and follow-up rates as well as the prevalence of major LARS.Feasibility outcomes will be analysed descriptively through the estimation of proportions with confidence intervals. Longitudinal patient reported outcome measures will be analysed according to scoring manuals and presented descriptively with reporting graphically over time. ETHICS AND DISSEMINATION Ethical approval has been granted by Wales REC1; Reference 22/WA/0025. The feasibility study is in the process of set up. The results of the feasibility trial will feed into the design of an expanded, international trial. TRIAL REGISTRATION NUMBER CT05319054.
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Yue Y, Chen X, Wang H, Cheng M, Zheng B. Mechanical bowel preparation combined with oral antibiotics reduces infectious complications and anastomotic leak in elective colorectal surgery: a pooled-analysis with trial sequential analysis. Int J Colorectal Dis 2023; 38:5. [PMID: 36622449 DOI: 10.1007/s00384-022-04302-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE A pooled analysis combined with trial sequential analysis (TSA) was conducted in order to explore the effect of mechanical bowel preparation (MBP) combined with oral antibiotic bowel decontamination (OAB) versus MBP alone on patients who have undergone colorectal resection. METHODS Comprehensive and systematic searches of PubMed, Embase, Cochrane Library, Web of Knowledge, and Clinical Trials.gov databases were conducted. The quality of literature was evaluated using Cochrane risk bias assessment tool as well as Newcastle-Ottawa Scale (NOS) score. A pooled analysis of randomized controlled trials (RCTs) and prospective studies was performed comparing patients who underwent colorectal resection and received MBP plus OAB or MBP alone. The outcome endpoints were the incidence of anastomotic leak (AL) and surgical site infection (SSI). TSA is a tool used to assess the reliability of currently available evidence to determine further clinical trial validation. RESULTS The analysis included a total of 22 studies involving 8852 patients, including 3016 patients in the MBP + OAB group and 4415 patients exposed to MBP alone. The pooled analysis showed that the incidence of postoperative anastomotic leak was significantly lower in the group treated with MBP plus OAB compared with MBP alone (OR = 0.43, 95% CI: 0.23-0.81, P = 0.009, I2 = 73%). The incidence of postoperative surgical site infections was significantly lower in the group exposed to the combination of MBP and OAB compared with MBP alone (OR = 0.38, 95% CI: 0.32-0.46, P < 0.0001, I2 = 24%). The TSA demonstrated significant benefits of MBP plus OAB intervention in terms of AL and SSI. CONCLUSION MBP combined with OAB significantly reduces the incidence of AL and SSI in patients after colorectal resection compared with MBP alone.
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Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation. Surg Endosc 2023; 37:3602-3609. [PMID: 36624218 PMCID: PMC10156761 DOI: 10.1007/s00464-022-09819-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/05/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL. METHOD A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion. RESULTS Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04). CONCLUSION The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04766060.
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Intraluminal Anastomotic Assessment Using Indocyanine Green Near-Infrared Imaging for Left-Sided Colonic and Rectal Resections: a Systematic Review. J Gastrointest Surg 2023; 27:615-625. [PMID: 36604377 DOI: 10.1007/s11605-022-05564-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICG-FA) has been used in colorectal surgery to assess anastomotic perfusion and reduce the risks of anastomotic leaks. The main objective of this paper is to review the data on the transanal application of ICG-FA for the intraluminal assessment of colorectal anastomosis. METHODS A literature search was conducted for articles published between 2011 and 2021 using PubMed and Cochrane databases, related to the application of ICG for the intraluminal assessment of colorectal anastomosis. Original scientific manuscripts, review articles, meta-analyses, and case reports were considered eligible. RESULTS A total of 305 studies have been identified. After abstract screening for duplicates, 285 articles remained. Of those, 271 were not related to the topic of interest, 4 were written in a language other than English, and 4 had incomplete data. Six articles remained for the final analysis. The intraluminal assessment of colorectal anastomosis with ICG-FA is feasible, safe, and may reduce the incidence of leaks. CONCLUSION The intraluminal assessment of anastomotic perfusion via ICG-FA may be a promising novel application of ICG technology. More data is needed to support this application further to reduce leak rates after colorectal surgery, and future randomized clinical trials are awaited.
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Kitaguchi D, Ito M. Optimal anastomotic technique in rectal surgery to prevent anastomotic leakage. Ann Coloproctol 2023; 39:97-105. [PMID: 36593572 PMCID: PMC10169556 DOI: 10.3393/ac.2022.00787.0112] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/23/2022] [Indexed: 01/04/2023] Open
Abstract
Complications after colorectal surgery remain inevitable, and anastomotic leakage is one of the most severe and potentially fatal complications. Generally, anastomotic leakage is associated with severe peritonitis, the need for emergency reoperation, and an increased mortality rate. Additionally, particularly after rectal cancer surgery, it has a negative impact on long-term outcomes, including postoperative anorectal function, local recurrence, and survival. To prevent anastomotic leakage, understanding the characteristics of each anastomotic technique and establishing a stable anastomotic procedure are important. Transanal total mesorectal excision (TaTME) is a relatively new advanced surgical access technique for pelvic dissection and facilitates different anastomotic techniques without the need for transabdominal rectal transection. Especially, stapled anastomosis in TaTME, also known as double purse-string circular stapled anastomosis or the single stapling technique (SST), has gained much attention as an alternative to the conventional double stapling technique (DST). In this article, we describe the DST, SST, and hand-sewn anastomosis as anastomotic techniques after rectal surgery, focusing mainly on the differences between conventional anastomotic techniques and SST in TaTME. Furthermore, the blood flow evaluation method for the reconstructive colon before anastomosis, which is extremely important in anastomotic leakage prevention regardless of the anastomotic type, is also described.
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Le-Nguyen A, Bourque CJ, Trudeau MO, Ducruet T, Faure C, Piché N. Indocyanine green fluorescence angiography in pediatric intestinal resections: A first prospective mixed methods clinical trial. J Pediatr Surg 2023; 58:82-88. [PMID: 36357227 DOI: 10.1016/j.jpedsurg.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to establish the feasibility and safety of the use of indocyanine green technology during pediatric intestinal resections. While indocyanine green fluorescence angiography (ICG-FA) has been advocated as an imaging technique to assess bowel perfusion in adults, few studies have evaluated this technology in a pediatric context. METHODS A prospective clinical trial was conducted. Patients 16 years old or younger undergoing a surgery potentially requiring an intestinal resection were eligible. Patients received a standardized intravenous injection of indocyanine green and intestinal perfusion was evaluated. The study endpoints included safety, impact on bowel resection and feasibility and acceptance of ICG-FA in this population. RESULTS From May 2020 to March 2021, 30 consecutive patients were included in this trial. Final analysis was done on 28 patients with a median age of 15.00 [6.36,85.00] weeks and weight of 5.58 [3.64,11.70] kg at surgery. Adequate fluorescence was achieved in less than one minute for all cases with an average dose of 0.14 mg/kg. No adverse event related to indocyanine green occurred. ICG-FA versus standard assessment of potential resection sites differed in 62% (95% IC 0.41-0.82) of our cases. Qualitative analysis demonstrated that 95% of the surgical team agreed that ICG-FA was safe. CONCLUSIONS The use of ICG-FA is feasible and safe for pediatric intestinal resections. Introduction of ICG-FA was simple and acceptance rates were high within the surgical team. This fluorescence imaging may be a valuable imaging technology for intestinal resections in pediatric surgery.
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Moon J, AlFarsi M, Marinescu D, AlQahtani M, Pang A, Ghitulescu G, Vasilevsky CA, Boutros M. Emergency colectomies in the NOAC era: a nationwide analysis demonstrating increased complications. Surg Endosc 2023; 37:660-668. [PMID: 36163564 DOI: 10.1007/s00464-022-09630-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/11/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies. METHODS All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002-2010) and anticoagulated patients in the NOAC era (2010-2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion. RESULTS Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R2 = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57-0.88) and transfusions (OR 0.71 95%CI 0.64-0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14-1.39). CONCLUSION Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed.
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Carvalho F, Qiu S, Panagi V, Hardy K, Tutcher H, Machado M, Silva F, Dinen C, Lane C, Jonroy A, Knox J, Worley L, Whibley J, Perren T, Thain J, McPhail J. Total Pelvic Exenteration surgery - Considerations for healthcare professionals. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:225-236. [PMID: 36030135 DOI: 10.1016/j.ejso.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and with the view of achieving the best outcomes and lessen short and long-term morbidities, a well-thought-out and coordinated multidisciplinary team approach, is crucial to the provision of safe and high-quality care. METHOD Using a nominal group technique and qualitative methodology, this article explores the current practices in the care of oncology patients who undergo TPE surgery, in a tertiary cancer centre, by highlighting considerations of a collaboratively multi-disciplinary team. RESULTS This article provides guidance on the multi-disciplinary team approach, relating to TPE surgery, with discussion of clinical concerns, and with the goal of high patient satisfaction, provision of effective care and the lessening of short and long-term morbidities. CONCLUSION Oncology patients that undergo TPE surgery benefit from the contribution of a diversified multidisciplinary team as skilled and competent care that meets patient's health and social care needs is provided in a holistic, comprehensive, and timely care manner. Improving patient's care, pathway and postoperative outcomes, with the use of clinical expertise and support from professionals in the multidisciplinary team, can maximise care.
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Garcia-Perez E, Aguirre-Larracoechea U, Portugal-Porras V, Azpiazu-Landa N, Telletxea-Benguria S. Frailty assessment has come to stay: Retrospective analysis pilot study of two frailty scales in oncological older patients undergoing colorectal surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:1-9. [PMID: 36682609 DOI: 10.1016/j.redare.2021.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/24/2021] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Colorectal cancer is a disease of the elderly and its main treatment is surgery. Frailty, a clinical syndrome of decreased reserve, increases with age and has been recognized as a predictive factor for postoperative mortality. Our primary objective was to assess the association between two frailty scores and mortality within the first year after surgery, by retrospectively linking frailty scores to mortality data and comparing the strength of their association with mortality to that of the ASA Classification. The frailty scales used were: the Modified Frailty Index (MFI) and, the Risk Analysis Index-A (RAI-A) and the G8 screening test (G8). As secondary objectives, we assessed the relationship of the frailty scales with morbidity and compared all the scales with the ASA. MATERIAL AND METHODS We retrospectively studied 172 patients aged 65 years and older who underwent laparoscopic colorectal surgery for cancer between January 2017 and June 2018, following them up for 1year after surgery. RESULTS Both morbidity and mortality were significantly associated with all frailty scale scores (p<.001). The more frailty, the greater probability of prolonged hospital stay, complications, readmissions and emergency department visits. Using each scale, patients were categorized into two groups (frail and non-frail patients). The C-indexes for 1-year mortality with the RAI-A and, MFI and G8 were 0.89 and, 0.86 and 0.86 respectively. On the other hand, ASA status is not strongly associated with mortality, with a C-index of .63. DISCUSSION Frailty scores should begin to influence medical and surgical strategies and further research is needed to develop guidelines for interventions in geriatric patients.
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Buitrago-Ruiz M, Martinez-Nicolas I, Soria-Aledo V. Validation of prolonged length of stay as a reliable measure of failure to rescue in colorectal surgery. Asian J Surg 2023; 46:126-131. [PMID: 35317966 DOI: 10.1016/j.asjsur.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/10/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Failure-to-rescue measures a hospital's response capacity to avoid the death of a patient after a complication. The aim of this study was to validate the use of prolonged length of stay to calculate failure-to-rescue rates as a substitute for traditional coding of complications in colorectal cancer surgery. METHOD We performed a cross-sectional between-instruments agreement study. Our study population was comprised of 204 colorectal cancer surgical patients from a public academic hospital during 2017 and 2018. We obtained two failure-to-rescue indicators from administrative data: an indicator using International Classification of Diseases, tenth edition, (ICD-10) codes; and another one using a cut-off point of prolonged length of stay as a predictor of patients with complications. Then, they were compared with a reference indicator from clinical records. RESULTS Failure-to-rescue rates were between 10 and 13.64 for the study site depending on which indicator was used. A hospital stay ≥10 days had the maximum Youden's index (0.6) and an area under the ROC curve of 0.87. This was used in the failure-to-rescue indicator using prolonged length, which obtained the highest agreement (any coefficient >0.75). CONCLUSION ICD-10 codes identified complications poorly. Prolonged length of stay could be a valid replacement of ICD-10 codes when measuring failure-to-rescue in administrative databases for colorectal surgical patients.
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Comparison of robotic vs laparoscopic left-sided colorectal cancer resections. J Robot Surg 2023; 17:205-213. [PMID: 35610541 PMCID: PMC9129896 DOI: 10.1007/s11701-022-01414-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
Robotic assisted surgery (RAS) has become increasingly adopted in colorectal cancer surgery. This study aims to compare robotic and laparoscopic approaches to left sided colorectal resections in terms of surgical outcomeswith no formal enhanced recovery programme. All patients undergoing robotic or laparoscopic left sided or rectal (high and low anterior resection) cancer surgery at a single tertiary referral centre over 3 years were included.A total of 184 consecutive patients from July 2017 to December 2020 were included in this study, with 40.2% (n=74/184) undergoing RAS. The median age at time of surgery was 68 years (IQR 60-73 years). RAS had a significantly shorter length of median stay of 3 days, compared to 5 days in the conventional laparoscopic surgery (CLS) group (p<0.001). RAS had a significantly lower rate of conversion to open surgery (0% vs 16.4%, p<0.001). The median operative time was also shorter in RAS (308 minutes), compared to CLS (326 minutes, p=0.019). The overall rate of any complication was 16.8%, with the RAS experiencing a lower complication rate (12.2% vs 20.0%, p=0.041). There was no significant difference in anastomotic leak rates between the two groups (4.0% vs 5.5%, p=0.673), or in terms of complete resection (R0) (robotic 98.6%, laparoscopic 100%, p=0.095). Robotic left sided colorectal surgery delivers equivalent oncological resection compared to laparoscopic approaches, with the added benefits of reduced length of stay and lower rates of conversion to open surgery. This has both clinical and healthcare economic benefits.
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Early and late anastomotic leak after colorectal surgery: A systematic review of the literature. Cir Esp 2023; 101:3-11. [PMID: 35882311 DOI: 10.1016/j.cireng.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/24/2022] [Indexed: 01/17/2023]
Abstract
The aim of this study was to review and to assess the quality of the scientific articles regarding early and late anastomotic leak (AL) after colorectal surgery and their risk factors. An electronic systematic search for articles on Colorectal Surgery, AL and its timing was undertaken using the MEDLINE database via PubMed, Cochrane and Embase. The selected articles were thoroughly reviewed and assessed for methodological quality using a validated methodology quality score (MINCIR score). This review was registered in the PROSPERO registry under ID: CRD42022303012. 9 articles were finally reviewed in relation to the topic of early and late anastomotic leak. There is a lack of consensus regarding the exact cut-off in time to define early and late anastomotic leak, but it is clear that they are two differentiated entities. The first, occurring in relation to technical factors; whereas the latter, is related to impaired healing.
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Caminsky NG, Moon J, Morin N, Alavi K, Auer RC, Bordeianou LG, Chadi SA, Drolet S, Ghuman A, Liberman AS, MacLean T, Paquette IM, Park J, Patel S, Steele SR, Sylla P, Wexner SD, Vasilevsky CA, Rajabiyazdi F, Boutros M. Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it? Surg Endosc 2023; 37:669-682. [PMID: 36195816 DOI: 10.1007/s00464-022-09580-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 08/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC. METHODS A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively. RESULTS Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients. CONCLUSIONS Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.
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Bona D, Danelli P, Sozzi A, Sanzi M, Cayre L, Lombardo F, Bonitta G, Cavalli M, Campanelli G, Aiolfi A. C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:166-179. [PMID: 36175720 DOI: 10.1007/s11605-022-05473-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/16/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery. METHODS Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD). RESULTS Twenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7-9%), and the median time to diagnosis was 6.9 days (range 3-10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23-0.85), 0.84 (95% CIs 0.18-0.86) and 0.84 (95% CIs 0.18-0.89) respectively. Negative likelihood ratios (LR-) showed moderate evidence to rule out AL on POD 3 (LR- 0.29), POD4 (LR- 0.24) and POD5 (LR- 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (-0.18) showed moderate evidence to rule out AL. CONCLUSIONS In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development.
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