Methodology for implementing early recovery after surgery protocols in colorectal surgery

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols in colorectal surgery leads to improved quality of care and more efficient resource utilization. Despite these positive outcomes, the penetration of ERAS protocols in the Czech Republic is low. The aim of this study is to present a general methodology for implementing an ERAS protocol in colorectal surgery.

METHODS

The methodology is based on the authors' extensive experience in implementing clinical protocols at various institutions in the Czech Republic, as well as published international experiences. This methodology is described in detail and supplemented with data obtained during implementation of an ERAS program at the author's institution.

RESULTS

The preparatory phase includes in-depth quality of care audits and preparation of an ERAS protocol. The purpose of the audits is to identify areas of care where standardization or targeted changes in clinical practice are desirable. The implementation phase involves staff training, technical implementation support, protocol dissemination, adherence monitoring, and evaluation of a pilot phase with subsequent protocol adjustments. The evaluation phase involves data collection, maintaining a prospective database, and regular assessments.

CONCLUSION

The presented methodology describes the individual steps in the process of implementing a clinical protocol into practice. This text can serve as a manual for implementing an ERAS protocol in colorectal surgery at any institution.

Robotic resection of the rectum - what are the advantages?

INTRODUCTION

Surgical treatment is the most important part of multimodal management of rectal cancer. In recent years, minimally invasive surgery has been preferred. Minimally invasive procedures include laparoscopy and more recently robotic surgery. Robotic surgery has been developed to eliminate the shortcomings of laparoscopy, especially the parallel position of instruments and their limited movement. The advantages of a robotic system should be most apparent in narrow and deep spaces, i.e. the lesser pelvis. The aim of this study was to analyze the short-term results of robot-assisted surgery for rectal tumors.

METHODS

The study is a retrospective analysis of a cohort of 220 patients with robotic-assisted surgery for rectal cancer. The cohort was analyzed in terms of length of surgery, blood loss, number of conversions to open surgery, completeness of TME, distal and circumferential resection margin positivity, length of hospital stays and number of 30-day rehospitalizations. In addition, 30-day postoperative morbidity and mortality were assessed using the Clavien-Dindo score.

RESULTS

Robotic-assisted surgeries lasted an average of 184 minutes. In total, 5 operations were converted, i.e. 2.3%. Complete mesorectum was achieved in 90% of the patients. Severe postoperative complications, Clavien-Dindo score 3-4, were observed in 14% of the patients. Anastomotic complications occurred in 9.6% of the patients. The mean length of the hospital stay was 8.4 days.

CONCLUSION

Robotic surgery for rectal tumors is a safe method with an acceptable rate of complications. An established training method and a high degree of standardization of the surgical procedures are indisputable advantages of robotic systems, making it possible to achieve very good results in a short time. In terms of perioperative and early postoperative outcomes, robotic surgery outperforms laparoscopic surgery in some parameters.

Impact of microsatellite status in early-onset colonic cancer

BACKGROUND

The molecular profile of early-onset colonic cancer is undefined. This study evaluated clinicopathological features and oncological outcomes of young patients with colonic cancer according to microsatellite status.

METHODS

Anonymized data from an international collaboration were analysed. Criteria for inclusion were patients younger than 50 years diagnosed with stage I-III colonic cancer that was surgically resected. Clinicopathological features, microsatellite status, and disease-specific outcomes were evaluated.

RESULTS

A total of 650 patients fulfilled the criteria for inclusion. Microsatellite instability (MSI) was identified in 170 (26.2 per cent), whereas 480 had microsatellite-stable (MSS) tumours (relative risk of MSI 2.5 compared with older patients). MSI was associated with a family history of colorectal cancer and lesions in the proximal colon. The proportions with pathological node-positive disease (45.9 versus 45.6 per cent; P = 1.000) and tumour budding (20.3 versus 20.5 per cent; P = 1.000) were similar in the two groups. Patients with MSI tumours were more likely to have BRAF (22.5 versus 6.9 per cent; P < 0.001) and KRAS (40.0 versus 24.2 per cent; P = 0.006) mutations, and a hereditary cancer syndrome (30.0 versus 5.0 per cent; P < 0.001; relative risk 6). Five-year disease-free survival rates in the MSI group were 95.0, 92.0, and 80.0 per cent for patients with stage I, II, and III tumours, compared with 88.0, 88.0, and 65.0 per cent in the MSS group (P = 0.753, P = 0.487, and P = 0.105 respectively).

CONCLUSION

Patients with early-onset colonic cancer have a high risk of MSI and defined genetic conditions. Those with MSI tumours have more adverse pathology (budding, KRAS/BRAF mutations, and nodal metastases) than older patients with MSI cancers.

Microsatellite instability in young patients with rectal cancer: molecular findings and treatment response

In this study of 400 patients with early-onset rectal cancer, 12.5 per cent demonstrated microsatellite instability (MSI). MSI was associated with a reduced likelihood of nodal positivity, an increased rate of pathological complete response, and improved disease-specific survival.

Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review

Importance

The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer.

Observations

Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts.

Conclusions and Relevance

The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

Enhanced recovery after surgery and mini-invasive approaches in rectal cancer surgery - short-term outcomes

INTRODUCTION

The aim of this study was to evaluate short-term outcomes of patients undergoing mini-invasive rectal resection within an ERAS (enhanced recovery after surgery) protocol.

METHODS

A prospectively managed database of patients undergoing rectal operations performed at our department between January 2015 and April 2020 was retrospectively analyzed. An ERAS protocol was implemented into clinical practice at our department in April 2016 and mini-invasive rectal procedures in May 2016. The ERAS group consisted of all patients who underwent mini-invasive rectal resections or amputations within the ERAS protocol. The control group consisted of patients who underwent open procedures and received standard perioperative care. The extracted data included basic patient characteristics, surgical data, postoperative recovery parameters, 30-day morbidity, length of postoperative stay and 30-day rehospitalization.

RESULTS

A total of 110 patients were included in the study: 67 patients in the ERAS group and 43 in the control group. Within the ERAS group 47 patients underwent robotic procedures and 20 had laparoscopic procedures. Patients in the ERAS group had significantly better clinical and laboratory recovery parameters except for postoperative nausea and vomiting. A significantly lower incidence of paralytic ileus (20.9% vs. 3%) and a shorter length of postoperative stay (13 days vs. 9 days) was found in the ERAS group. The rehospitalization rate and 30-day morbidity were not different between the ERAS and control group.

CONCLUSIONS

Implementation of the ERAS protocol in combination with mini-invasive approaches leads to better short-term postoperative outcomes after rectal surgery.

Static compression is associated with decreased diffusivity of dextrans in cartilage explants

The chondrocytes of adult articular cartilage rely upon transport phenomena within their avascular extracellular matrix for many biological activities. Therefore, changes in matrix structure which influence cytokine transport parameters may be an important mechanism involved in the chondrocyte response to tissue compression. With this hypothesis in mind, partitioning and diffusion of 3-, 10-, and 40-kDa dextrans conjugated to tetramethylrhodamine, and 430-Da tetramethylrhodamine itself, were measured within statically compressed bovine articular cartilage explants using a novel experimental apparatus and desorption fluorescence method. Partitioning and diffusion were examined as functions of solute molecular weight and matrix proteoglycan density, and diffusion was measured versus static compression up to 35% volumetric strain. In general, partition coefficients and diffusivities were found to decrease with increasing solute molecular weight. In addition, for a given solute, diffusivities decreased significantly with increasing static compression. Results therefore suggest a possible role for transport limitations of relatively large molecular weight solutes within the extracellular matrix in mediating the biological response of chondrocytes to cartilage compression.

Short-term binding of fibroblasts to fibronectin: optical tweezers experiments and probabilistic analysis

The biophysical properties of the interaction between fibronectin and its membrane receptor were inferred from adhesion tests on living cells. Individual fibroblasts were maintained on fibronectin-coated glass for short time periods (1-16 s) using optical tweezers. After contact, the trap was removed quickly, leading to either adhesion or detachment of the fibroblast. Through a stochastic analysis of bond kinetics, we derived equations of adhesion probability versus time, which fit the experimental data well and were used to compute association and dissociation rates (k+ = 0.3-1.4 s(-1) and koff = 0.05-0.25 s(-1), respectively). The bond distribution is binomial, with an average bond number < or = 10 at these time scales. Increasing the fibronectin density (100-3000 molecules/microm2) raised k+ in a diffusion-dependent manner, leaving koff relatively unchanged. Increasing the temperature (23-37 degrees C) raised both k+ and koff, allowing calculation of the activation energy of the chemical reaction (around 20 kBT). Increasing the compressive force on the cell during contact (up to 60 pN) raised k+ in a logarithmic manner, probably through an increase in the contact area, whereas koff was unaffected. Finally, by varying the pulling force to detach the cell, we could distinguish between two adhesive regimes, one corresponding to one bond, the other to at least two bonds. This transition occurred at a force around 20 pN, interpreted as the strength of a single bond.