Comparison of early surgical outcomes of robotic and laparoscopic colorectal cancer resection reported by a busy district general hospital in England

Robotic platforms provide a stable tool with high-definition views and improved ergonomics compared to laparoscopic approaches. The aim of this retrospective study was to compare the intra- and short-term postoperative results of oncological resections performed robotically (RCR) and laparoscopically (LCR) at a single centre. Between February 2020 and October 2022, retrospective data on RCR were compared to LCR undertaken during the same period. Parameters compared include total operative time, length of stay (LOS), re-admission rates, 30-day morbidity. 100 RCR and 112 LCR satisfied inclusion criteria. There was no difference between the two group's demographic and tumour characteristics. Overall, median operative time was shorter in LCR group [200 vs. 247.5 min, p < 0.005], but this advantage was not observed with pelvic and muti-quadrant resections. There was no difference in the rate of conversion [5(5%) vs. 5(4.5%), p > 0.95]. With respect to perioperative outcomes, there was no difference in the overall morbidity, or mortality between RCR and LCR, in particular requirement for blood transfusion [3(3%) vs. 5(4.5%), p 0.72], prolonged ileus [9(9%) vs. 15(13.2%), p 0.38], surgical site infections [5(4%) vs. 5(4.4%), p > 0.95], anastomotic leak [7(7%) vs. 5(4.4%), p 0.55], and re-operation rate [9(9%) vs. 7(6.3%), p 0.6]. RCR had shorter LOS by one night, but this did not reach statistical significance. No difference was observed in completeness of resection but there was a statically significant increase in lymph node harvest in the robotic series. Robotic approach to oncological colorectal resections is safe, with comparable intra- and peri-operative morbidity and mortality to laparoscopic surgery.

Laparoscopic right hemicolectomy with complete mesocolic excision and D3 lymphadenectomy using the open book approach: a video vignette

According to the concept of total mesorectal excision for rectal cancer, Hohenberger translated this concept to colonic cancer by introducing complete mesocolic excision (CME). The concept of this surgical technique was further elucidated by Benz et al. in the form of an open book approach. This article presents and demonstrates in a video a case of laparoscopic right hemicolectomy with CME and D3 lymphadenectomy using open book approach in the treatment of a T3N1M0 distal ascending colonic adenocarcinoma. The final pathology report confirmed moderately differentiated adenocarcinoma with a maximum tumor size of 55 mm and 0/60 lymph nodes. The mesocolic fascia was intact and R0 was achieved. The final staging was pT3pN0pM0. However, D3 lymphadenectomy is not universally adopted due to concerns of higher morbidity we believe that with adequate training and supervision CME with D3 LDN is feasible and safe to be offered to all right-sided colorectal cancers with curative intent treatment.

Emergency transabdominal preperitoneal (TAPP) repair of a strangulated obturator hernia: A literature review and video vignette

Obturator hernia (OH), a rare and potentially life-threatening condition, presents diagnostic and therapeutic challenges. This review article comprehensively delves into the clinical features, diagnosis, and management of OH, with a particular emphasis on the pivotal role of computed tomography (CT) in timely and accurate diagnosis. Delays, particularly in contrast-enhanced CT, dramatically increase mortality due to potential bowel strangulation. To illustrate the challenges and complexities surrounding OH, we present a video vignette of a 74-year-old female patient who presented with symptoms suggestive of bowel obstruction (BO) secondary to a strangulated left-sided OH. This patient case complements the theoretical framework established in the review, serving as a practical example for healthcare professionals. Her presentation included abdominal pain, absence of flatus and bowel movements, and abdominal distension. Laboratory tests demonstrated a mildly elevated white blood cell count and C-reactive protein. CT imaging confirmed the diagnosis of a strangulated OH with an ischemic small bowel. An emergency laparoscopy was undertaken, and the hernia was repaired using the transabdominal preperitoneal approach. A portion of the ischemic small bowel was resected through a 5-cm extension of the umbilical port, and an anastomosis was performed using a modified Barcelona technique. The surgery was successfully completed without immediate or long-term complications. This case highlights the crucial role of timely CT diagnosis and minimally invasive surgical management in achieving improved outcomes in acute BO secondary to OH, particularly when facilitated by pre-operative CT planning.

Faecal Immunochemical Testing to Detect Colorectal Cancer in Symptomatic Patients: A Diagnostic Accuracy Study

(1) Background: NHS England recommended faecal immunochemical testing (FIT) for symptomatic patients in June 2020 to rationalise limited diagnostic services during COVID-19. (2) Aim: to investigate the diagnostic performance of FIT, analysing the proportion of FIT-negative colorectal cancers (CRC) missed in symptomatic patients and how this risk could be mitigated. (3) Design and Setting: a retrospective study of biochemistry and cancer databases involving patients referred from primary healthcare with suspected CRC to a single secondary care trust in North East London. (4) Methods: a retrospective cohort diagnostic accuracy study was undertaken to determine the performance of FIT for detecting CRC at 10 µgHb/g. (5) Results: between January and December 2020, 7653 patients provided a stool sample for FIT analysis; 1679 (22%) samples were excluded due to inadequate or incorrect specimens; 48% of suspected CRC referrals completed FIT before evaluation; 86 FIT tested patients were diagnosed with histologically proven CRC. At 10 µgHb/g, FIT performance was comparable with the existing literature with a sensitivity of 0.8140 (95% CI 0.7189-0.8821), a specificity of 0.7704 (95% CI 0.7595-0.7809), a positive predictive value (PPV) of 0.04923 (95% CI 0.03915-0.06174), a negative predictive value (NPV) of 0.9965 (95% CI 0.9943-0.9978), and a likelihood ratio (LR) of 3.545; 16 patients with CRC had an FIT of ≤10 µgHb/g (18.6% 95% CI 11.0-28.4%). (6) Conclusions: this study raises concerns about compliance with FIT testing and the incidence of FIT-negative CRC at the NICE recommended threshold and how this risk can be mitigated without colonic imaging. Whilst FIT may have facilitated prioritisation during COVID-19, we must be cautious about using FIT alone to determine which patients are referred to secondary care or receive further investigation.

Radiofrequency thermocoagulation of haemorrhoids: learning curve of a novel approach

Haemorrhoidal disease (HD) is a common condition that often requires surgical treatment. In comparison with other traditional techniques, radiofrequency thermocoagulation (RFTC) has multiple advantages to traditional repairs and can be a good alternative in surgical management of HD. We retrospectively analysed 20 patients with Grades 2 (n = 6, 30%) and 3 (n = 12, 70%) haemorrhoids undergoing RFTC from 1 September 2019 to 31 December 2021. Outcomes including post-operative (PO) pain, immediate/late PO complications, recurrence and patient satisfaction were assessed. Twenty cases were included in this case series. All pathological symptoms showed significant improvement in PO period. Eight complications were noted, including minor bleeding (n = 2), bleeding that required admissions (n = 3), pain (n = 2) and recurrence (n = 1). The mean time off work is 7 days and all patients were satisfied or very satisfied PO as per telephone questionnaire. RFTC is a safe and effective solution in the management of HD and is a good alternative to conventional procedures.

TU4.1 Single-center experience in robotic-assisted colorectal surgery during COVID pandemic: First 72 cases

Aim

To present an analysis of the first 2-years’ experience of robotic-assisted colorectal procedures (RACP) using the DaVinci Xi platform.

Methods

This data were prospectively collected and include 72 RACP between February 2020 and December 2021.Indications were: malignancy in 74.3%, diverticular disease 10%, inflammatory bowel disease 8.6%, rectal prolapse 4.3%, intussusception 1.4% and recurrent volvulus 1.4%.

Results

Over the 13-month study period, 72 RACP were performed including elective 57 cases and 15 semi-elective cases. These comprised: 25 right hemicolectomies, 25 high anterior resections, 6 extended right hemicolectomies,4 low anterior resections, 4 subtotal colectomies 2 restorative proctectomies, 3 abdominoperineal excisions of the rectum, 3 rectopexies that were performed. 51.2% were female and 48.6% were male with a median age of 45 years (22–85 years) and the median body mass index was 31 (18–46) kg/m2. Preoperative American Society of Anaesthesiology scores were reported as 1–2 in 72.9% (n=51) of patients and 27.1%(n=19) as 3. The median length of stay was 5 days (1–35), with readmission rate within 30 days of 8.6% (n=6) that were resolved conservatively. The mean operating time was 268 minutes and the mean console operative time was 158 minutes, with only 3 (4.3%) reported cases of conversion to open. The incidence of postoperative complications was 24.3% (Clavien–Dindo (CD) I/II- 12.9%, CD III- 10%, and CD V-1 case with superimposed COVID 19 within 30 days.

Conclusion

RACP is a safe and viable modality in the treatment of colorectal conditions and can be introduced safely with appropriate guidance and proctorship.

TU4.2 Robotic surgery for colorectal cancer: a single-center experience

Aim

To present our learning-curve data for patients that underwent robotic-assisted colorectal surgery (RCRS) at a large NE London DGH.

Methods

We report our data from 50 initial colorectal cancer resections, performed by two surgeons. We report the gender, age, histopathology, surgery performed, surgical time, conversion, post-operative complications, and hospital stay.

Results

The first 50 patients who underwent RCRS between February 2020 and December 2021 for malignancy were included. Twenty-one were right hemicolectomies, 16 high anterior resection, 6 extended right hemicolectomies, 4 low anterior resections (including a planned robotic boari flap in 1 case by a trained urologist), 3 abdominoperineal excisions of rectum. The male to female ratio was 1:1 and the mean age was 65 (range: 22–85) years. The ASA class distribution was 4% ASA I, 64% ASA II, 32% ASA III.

The median surgical time was 263 minutes (120–620) with median console time 136 minutes (50–540), the median hospital stay 5 days (range: 2–35) and a conversion rate of 6% (3/50 patients). The most common post-operative complications were ileus 4% (4/50), wound infection 6% (3/50), anastomotic leak 6% (3/50), and abscess formation 2% (1/50). 1 mortality occurred in a patient with an operated leak who contracted COVID-19. All patients underwent confirmed R0 resections with a negative CRM.

Conclusion

We report our first 50 robotic cases for colorectal malignancy, showing that robotic-assisted surgery can be performed with low rates of conversion 3 cases (6%) and low rates of post-operative complications despite a challenging patient demographic and a sharp learning curve.

P-BN06 Percutaneous cholecystostomy rates are increased following COVID-19 induced disruption to elective surgical pathways

Background

The COVID-19 pandemic has led to major service disruptions, including the cessation of elective laparoscopic cholecystectomies (LC), causing delays in managing symptomatic gallstones. We hypothesised that this would lead to an increased need for percutaneous cholecystostomy (PC) for acute cholecystitis.

Methods

We performed a retrospective cohort study in a single NHS trust. We included all patients who underwent either LC or PC during the periods of March 1st – August 31st over the years 2019 and 2020. Patient data was obtained from prospectively maintained patient electronic notes. Data are presented as median and interquartile ranges for continuous data and the percentages for categorical data and compared with Mann-Whitney U-test and Fisher’s exact tests respectively.

Results

We observed a substantial reduction in the number of LC performed in 2020 (n = 99) compared to 2019 (n = 198), whilst the number of PC performed in 2020 (n = 35) was more than double that in 2019 (n = 17) (Fig.1). This increase in numbers persisted even after our LC service was restarted. Comparing the patients who underwent PC in both years, there were no significant differences in age (2019: 68 (45-76) vs 2020: 72 (57-81), p = 0.41),  comorbidities (Charlson comorbidity index≥4: 10 (59%) vs 16 (46%), p = 0.56), or in-hospital mortality (2019: 2 (12%) vs 2020: 3 (9%), p = 0.99). As a proportion of all biliary interventions for cholelithiasis, PC increased from 8% (17/214) in 2019 to 26% (35/134) in 2020 (p < 0.001).

Conclusions

These results show how the cessation of LC service was directly related to increased numbers of invasive ‘damage control’ procedures for acute cholecystitis, emphasising the importance of maintaining COVID-secure surgical pathways. The numbers of PC remained high even after the restart of LC service, consistent with a ‘COVID shadow’ resulting from interruptions to elective services that impacts patient care for a prolonged period.

The relaxation behavior of supercooled and glassy imidacloprid

Employing dielectric spectroscopy, oscillatory shear rheology, and calorimetry, the present work explores the molecular dynamics of the widely used insecticide imidacloprid above and below its glass transition temperature. In its supercooled liquid regime, the applied techniques yield good agreement regarding the characteristic structural (alpha) relaxation times of this material. In addition, the generalized Gemant-DiMarzio-Bishop model provides a good conversion between the frequency-dependent dielectric and shear mechanical responses in its viscous state, allowing for an assessment of imidacloprid's molecular hydrodynamic radius. In order to characterize the molecular dynamics in its glassy regime, we employ several approaches. These include the application of frequency-temperature superposition (FTS) to its isostructural dielectric and rheological responses as well as use of dielectric and calorimetric physical aging and the Adam-Gibbs-Vogel model. While the latter approach and dielectric FTS provide relaxation times that are close to each other, the other methods predict notably longer times that are closer to those reflecting a complete recovery of ergodicity. This seemingly conflicting dissimilarity demonstrates that the molecular dynamics of glassy imidacloprid strongly depends on its thermal history, with high relevance for the use of this insecticide as an active ingredient in technological applications.