Locoregional Failure During and After Short-course Radiotherapy Followed by Chemotherapy and Surgery Compared With Long-course Chemoradiotherapy and Surgery: A 5-Year Follow-up of the RAPIDO Trial.

OBJECTIVE: To analyze risk and patterns of locoregional failure (LRF) in patients of the RAPIDO trial at 5 years. BACKGROUND: Multimodality treatment improves local control in rectal cancer. Total neoadjuvant treatment (TNT) aims to improve systemic control while local control is maintained. At 3 years, LRF rate was comparable between TNT and chemoradiotherapy in the RAPIDO trial. METHODS: A total of 920 patients were randomized between an experimental (EXP, short-course radiotherapy, chemotherapy, and surgery) and a standard-care group (STD, chemoradiotherapy, surgery, and optional postoperative chemotherapy). LRFs, including early LRF (no resection except for organ preservation/R2 resection) and locoregional recurrence (LRR) after an R0/R1 resection, were analyzed. RESULTS: Totally, 460 EXP and 446 STD patients were eligible. At 5.6 years (median follow-up), LRF was detected in 54/460 (12%) and 36/446 (8%) patients in the EXP and STD groups, respectively ( P =0.07), in which EXP patients were more often treated with 3-dimensional-conformed radiotherapy ( P =0.029). In the EXP group, LRR was detected more often [44/431 (10%) vs. 26/428 (6%); P =0.027], with more often a breached mesorectum (9/44 (21%) vs. 1/26 (4); P =0.048). The EXP treatment, enlarged lateral lymph nodes, positive circumferential resection margin, tumor deposits, and node positivity at pathology were the significant predictors for developing LRR. Location of the LRRs was similar between groups. Overall survival after LRF was comparable [hazard ratio: 0.76 (95% CI, 0.46-1.26); P =0.29]. CONCLUSIONS: The EXP treatment was associated with an increased risk of LRR, whereas the reduction in disease-related treatment failure and distant metastases remained after 5 years. Further refinement of the TNT in rectal cancer is mandated.

Evaluation of National Surgical Practice for Lateral Lymph Nodes in Rectal Cancer in an Untrained Setting.

BACKGROUND: Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level. METHODS: Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either 'node-picking' (the removal of an individual LLN) or 'partial regional node dissection' (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those  undergoing only rectal resection. RESULTS: Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7-3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2-2.5, p = 0.874). CONCLUSION: Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.

Uptake of robot-assisted colon cancer surgery in the Netherlands.

BACKGROUND: The robot-assisted approach is now often used for rectal cancer surgery, but its use in colon cancer surgery is less well defined. This study aims to compare the outcomes of robotic-assisted colon cancer surgery to conventional laparoscopy in the Netherlands. METHODS: Data on all patients who underwent surgery for colon cancer from 2018 to 2020 were collected from the Dutch Colorectal Audit. All complications, readmissions, and deaths within 90 days after surgery were recorded along with conversion rate, margin and harvested nodes. Groups were stratified according to the robot-assisted and laparoscopic approach. RESULTS: In total, 18,886 patients were included in the analyses. The operative approach was open in 15.2%, laparoscopic in 78.9% and robot-assisted in 5.9%. The proportion of robot-assisted surgery increased from 4.7% in 2018 to 6.9% in 2020. There were no notable differences in outcomes between the robot-assisted and laparoscopic approach for Elective cT1-3M0 right, left, and sigmoid colectomy. Only conversion rate was consistently lower in the robotic group. (4.6% versus 8.8%, 4.6% versus 11.6%, and 1.6 versus 5.9%, respectively). CONCLUSIONS: This nationwide study on surgery for colon cancer shows there is a gradual but slow adoption of robotic surgery for colon cancer up to 6.9% in 2020. When comparing the outcomes of right, left, and sigmoid colectomy, clinical outcomes were similar between the robotic and laparoscopic approach. However, conversion rate is consistently lower in the robotic procedures.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer.

BACKGROUND: The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity. METHODS: Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity. RESULTS: In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%. CONCLUSIONS: The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

Robot-Assisted Total Mesorectal Excision Versus Laparoscopic Total Mesorectal Excision: A Retrospective Propensity Score-Matched Cohort Analysis in Experienced Centers.

BACKGROUND: The superiority of robot-assisted over laparoscopic total mesorectal excision has not been proven. Most studies do not consider the learning curve while comparing the surgical technique. OBJECTIVE: This study aims to compare laparoscopic with robot-assisted total mesorectal excision performed by surgeons who completed the learning curve of the technique. DESIGN: This is a multicenter retrospective propensity score-matched analysis. SETTINGS: The study was performed in 2 large, dedicated robot-assisted hospitals and 5 large, dedicated laparoscopic hospitals. PATIENTS: Patients were included if they underwent a robot-assisted or laparoscopic total mesorectal excision for rectal cancer with curative intent at a dedicated center for the minimally invasive technique between January 1, 2015, and December 31, 2017. INTERVENTIONS: We compared robot-assisted with laparoscopic total mesorectal excision. MAIN OUTCOME MEASURES: The main outcome was conversion to laparotomy during surgery. Secondary outcomes were postoperative morbidity and positive circumferential resection margin. RESULTS: A total of 884 patients were included and, after matching, 315 patients per treatment group remained. Conversion was similar between laparoscopic and robot-assisted total mesorectal excision (4.4% vs 2.5% (p = 0.20)). Positive circumferential resection margin was equal (3.2% vs 4.4% (p = 0.41)). Overall morbidity was comparable as well, although a lower rate of wound infections was observed in the robot-assisted group (5.7% vs 1.9% (p = 0.01)). More primary anastomoses were constructed in the robot-assisted group (50.8% vs 68.3% (p < 0.001)). Finally, more open procedures were performed in dedicated laparoscopic centers, with an overrepresentation of cT4N+ tumors in this group. LIMITATIONS: This is a retrospective multicenter cohort; however, propensity score matching was applied to control for confounding by indication. CONCLUSIONS: Robot-assisted and laparoscopic total mesorectal excision are equally safe in terms of short-term outcomes. However, with the robot-assisted approach, more primary anastomoses were constructed, and a lower wound infection rate was observed. See Video Abstract at http://links.lww.com/DCR/B677.ESCISIÓN MESORRECTAL TOTAL ASISTIDA POR ROBOT VERSUS ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA: UNA PUNTUACIÓN DE PROPENSIÓN RETROSPECTIVA ANÁLISIS DE COHORTES EMPAREJADAS EN CENTROS EXPERIMENTADOS. ANTECEDENTES: No se ha demostrado la superioridad de la escisión mesorrectal total asistida por robot sobre la laparoscópica. La mayoría de los estudios no tienen en cuenta la curva de aprendizaje al comparar la técnica quirúrgica. OBJETIVO: Este estudio tiene como objetivo comparar la escisión mesorrectal total laparoscópica con la asistida por robot realizada por cirujanos que completaron la curva de aprendizaje de la técnica. DISEO: Este es un análisis multicéntrico retrospectivo emparejado por puntuación de propensión. AJUSTES: El estudio se realizó en dos grandes hospitales dedicados asistidos por robots y cinco grandes hospitales laparoscópicos dedicados. PACIENTES: Se incluyeron pacientes que se sometieron a escisión mesorrectal total asistida por robot o laparoscópica para cáncer de recto con intención curativa, en un centro dedicado a la técnica mínimamente invasiva entre el 1 de enero de 2015 y el 31 de diciembre de 2017. INTERVENCIONES: Comparamos la escisión mesorrectal total asistida por robot con la laparoscópica. PRINCIPALES MEDIDAS DE RESULTADO: El principal resultado fue la conversión a laparotomía durante la cirugía. Los resultados secundarios fueron la morbilidad posoperatoria y el margen circunferencial positivo. RESULTADOS: Se incluyó a un total de 884 pacientes y, después de emparejar, quedaron 315 pacientes por grupo de tratamiento. La conversión fue similar entre la escisión mesorrectal total laparoscópica y asistida por robot (4,4% frente a 2,5% [p = 0,20]). El margen de resección circunferencial positivo fue igual (3,2% vs 4,4% [p = 0,41]). La morbilidad general también fue comparable, aunque se observó una menor tasa de infecciones de heridas en el grupo asistido por robot (5,7% frente a 1,9% [p = 0,01]). Se construyeron más anastomosis primarias en el grupo asistido por robot (50,8% frente a 68,3% [p < 0,001]). Finalmente, se realizaron procedimientos más abiertos en centros laparoscópicos dedicados, con una sobrerrepresentación de tumores cT4N + en este grupo. LIMITACIONES: Ésta es una cohorte multicéntrica retrospectiva; sin embargo, se aplicó el emparejamiento por puntuación de propensión para controlar los factores de confusión por indicación. CONCLUSIONES: La escisión mesorrectal total asistida por robot y laparoscópica son igualmente seguras en términos de resultados a corto plazo. Sin embargo, con el abordaje asistido por robot, se construyeron más anastomosis primarias y se observó una menor tasa de infección de la herida. Consulte Video Resumen en http://links.lww.com/DCR/B677. (Traducción-Dr. Gonzalo Hagerman).

The Mesentery in Robot-Assisted Total Mesorectal Excision.

In recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed.

A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer.

BACKGROUND: Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC. METHODS: A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to "colon tumour," "stenosis or obstruction and surgery," and "decompression or stents." All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival. RESULTS: Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19-54%) after emergency resection, and 30% (range 7-44%) after staged treatment. The average mortality rate was 7.2% (range 0-14.5%) after emergency resection and 1.2% (range 0-6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments. CONCLUSIONS: The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection.

Differences in Metastatic Pattern in Patients Presenting With or Without Obstructing Colorectal Cancer: A Retrospective Observational Study of 2595 Patients.

BACKGROUND: Little is known about metastatic patterns in patients with obstructing colorectal cancer (CRC). OBJECTIVE: The aim of this study was to determine if metastatic patterns in patients with CRC differ between patients with or without obstruction. METHODS: This single-center, observational, retrospective cohort study includes patients who underwent surgery for CRC between 2004 and 2015 in our hospital. Patients were divided into two groups-patients with or without obstructing CRC. All anatomic sites of distant metastases were reported. Differences in synchronous and metachronous metastases were compared between both groups. RESULTS: A total of 2595 patients were included for analysis, of whom 315 (12%) presented with obstructing CRC. Synchronous metastases were diagnosed in 483 patients (19%). Patients with obstructing CRC and synchronous metastases, were diagnosed with peritoneal metastases more often than patients without obstruction (37% vs. 16%; p < 0.01). With regard to the location of the tumor, obstructing right-sided CRC patients were diagnosed with peritoneal metastases more often than patients without obstruction (52% vs. 21%; p < 0.01). Additionally, metachronous metastases were found significantly more often in patients with obstructing CRC (27%) compared with patients without obstruction (15%; p < 0.01). CONCLUSIONS: Patients with obstructing CRC have more advanced tumor stage compared with patients without obstructing CRC. Synchronous peritoneal metastases are more often encountered in patients with obstructing CRC compared with patients without obstruction. This difference is due to the raised presence of synchronous peritoneal metastases in patients with obstructed right-sided colonic cancer. Furthermore, metachronous metastases are more often found in patients with obstructing CRC.

MRI-based guidelines for selective neoadjuvant treatment in rectal cancer: Does MRI adequately predict the indication for radiotherapy in daily practice in a large teaching hospital.

OBJECTIVES: According to new Dutch guidelines for rectal cancer, MRI-defined tumour stage determines whether preoperative radiotherapy is indicated. Therefore, we sought to evaluate if preoperative MRI accurately predicts the indication for neoadjuvant treatment in rectal cancer cases in daily practice according to the new Dutch guidelines. METHODS: Data for all rectal cancer patients who underwent mesorectal excision in our hospital, between January 2011 and January 2018 were collected retrospectively. We compared histopathologic outcome with tumour staging on preoperative MRI for patients who received no radiotherapy prior to resection or short-course radiotherapy directly followed by resection. RESULTS: Of 223 patients treated according to the old guidelines, 94% received neoadjuvant therapy. Of 301 patients treated according to the new guidelines, only 49% did. Under the old guidelines, MRI predicted lymph node metastases with a sensitivity of 74.2% and a specificity of 52.6%. With the new guidelines, sensitivity was 47.5% and specificity was 77.3%. The new guidelines resulted in 45% more patients not being exposed to disadvantages of radiotherapy, but 13% of all patients were undertreated. CONCLUSIONS: Concordance between clinical lymph node staging on preoperative MRI and histopathologic staging is limited, resulting in many rectal cancer patients not receiving adequate neoadjuvant therapy.

Preoperative Oral Antibiotic Prophylaxis Reduces Surgical Site Infections After Elective Colorectal Surgery: Results From a Before-After Study.

BACKGROUND: Surgical site infections (SSIs) are common complications after colorectal procedures and remain an important source of morbidity and costs. Preoperative oral antibiotic prophylaxis is a potential infection control strategy, but its effectiveness without simultaneous use of mechanical bowel preparation (MBP) is unclear. In this study, we aimed to determine whether preoperative oral antibiotics reduce the risk of deep SSIs in elective colorectal surgery. METHODS: We performed a before-after analysis in a teaching hospital in the Netherlands. Patients who underwent surgery between January 2012 and December 2015 were included. On 1 January 2013, oral antibiotic prophylaxis with tobramycin and colistin was implemented as standard of care prior to colorectal surgery. The year before implementation was used as the control period. The primary outcome was a composite of deep SSI and/or mortality within 30 days after surgery. RESULTS: Of the 1410 patients, 352 underwent colorectal surgery in the control period and 1058 in the period after implementation of the antibiotic prophylaxis. We observed a decrease in incidence of the primary endpoint of 6.2% after prophylaxis implementation. When adjusted for confounders, the risk ratio for development of the primary outcome was 0.58 (95% confidence interval, 0.40-0.79). Other findings included a decreased risk of anastomotic leakage and a reduction in the length of postoperative stay. CONCLUSIONS: Preoperative oral antibiotic prophylaxis prior to colorectal surgery is associated with a significant decrease in SSI and/or mortality in a setting without MBP. Preoperative oral antibiotics can therefore be considered without MBP for patients who undergo colorectal surgery.

Improving the Quality of MRI Reports of Preoperative Patients With Rectal Cancer: Effect of National Guidelines and Structured Reporting.

OBJECTIVE: Since the implementation of new guidelines for rectal cancer in The Netherlands in April 2014, clinical stage as seen at preoperative MRI indicates whether neoadjuvant therapy is necessary before rectal cancer surgery. Therefore, the importance of correct MRI interpretation has increased. The aim of this study was to evaluate the completeness of MRI reports of rectal cancer and the effect of implementation of the new guidelines and standardized reporting on the completeness of these reports. MATERIALS AND METHODS: Data were collected from all patients who consecutively underwent rectal cancer surgery at one hospital between January 2011 and July 2017. Data were extracted from electronic patient records. RESULTS: The study included 492 MRI examinations. Before implementation of the new guidelines, a median of 4 of 10 items (interquartile range [IQR], 3-6 items) were described in each MRI report. After implementation of the new guidelines, the number of items described improved significantly (median, 7 items; IQR, 6-8 items; p < 0.001). Implementation of a standardized report led to further significant improvement (median, 9 items; IQR, 9-10 items; p < 0.001). The items scored most frequently were distance between the tumor and the anal verge (85.6%) and length of the tumor (87.6%). The items scored least were presence or absence of extramural venous invasion (21.1%) and morphologic features of the tumor (24.6%). CONCLUSION: Implementation of a standardized protocol and a standardized reporting system for MRI in preoperative staging of rectal cancer results in a more complete MRI report.

Ileus caused by obstructing colorectal cancer-impact on long-term survival.

PURPOSE: It is unclear whether obstructing colorectal cancer (CRC) has a worse prognosis than non-obstructing CRC. Of CRC patients, 10-28% present with symptoms of acute obstruction. Previous studies regarding obstruction have been primarily based on short-term outcomes, risk factors and treatment modalities. With this study, we want to determine the long-term survival of patients presenting with acute obstructive CRC. METHODS: This single-centre observational retrospective cohort study includes all CRC patients who underwent surgery between December 2004 and 2010. Patients were divided into two groups: ileus and no ileus. Survival analyses were performed for both groups. Additional survival analyses were performed in patients with and without synchronous metastases. The primary outcome was survival in months. RESULTS: A total of 1236 patients were included in the analyses. Ileus occurred in 178 patients (14.4%). The 5-year survival for patients with an ileus was 32% and without 60% (P < 0.01). In patients without synchronous metastases, survival with and without an ileus was 40.9 and 68.4%, respectively (P < 0.01). If ileus presentation was complicated by a colon blowout, 5-year survival decreased to 29%. No significant difference was found in patients with synchronous metastases. Survival at 5 years in this subgroup was 10 and 12% for patients with and without an ileus, respectively (P = 0.705). CONCLUSIONS: Patients with obstructive CRC have a reduced short-term overall survival. Also, long-term overall survival is impaired in patients who present with acute obstructive CRC compared to patients without obstruction.

Does robotic rectal cancer surgery improve the results of experienced laparoscopic surgeons? An observational single institution study comparing 168 robotic assisted with 184 laparoscopic rectal resections.

BACKGROUND: The role of robotic assistance in colorectal cancer surgery has not been established yet. We compared the results of robotic assisted with those of laparoscopic rectal resections done by two surgeons experienced in laparoscopic as well as in robotic rectal cancer surgery. METHODS: Two surgeons who were already experienced laparoscopic colorectal surgeons in 2005 started robotic surgery with the daVinci SI system in 2012. All their rectal cancer resections between 2005 and 2015 were retrieved from a prospectively recorded colorectal database of routinely collected patient data. Multi-organ resections were excluded. Patient data, diagnostic data, data on preceding operations and neoadjuvant treatment, perioperative and operative data, logistic data, and short-term outcomes were gathered. Multivariable analyses (multiple linear and logistic regression) were used to assess differences in several outcomes between the two resection methods while adjusting for all potential confounders we could identify. Results are presented as adjusted mean differences for continuous outcome variables or as adjusted odds ratios (OR) for dichotomous outcome variables. RESULTS: Three hundred and fifty-two patients with rectal cancers were identified: 168 robotic and 184 conventional laparoscopic cases, 178 operated by surgeon A and 174 operated by surgeon B. Adjusted mean operation time was 215 min in the robotic group which was 40 min (95% CI 24-56; p < 0.0005) longer than the 175 min in the laparoscopic group. Robotic treatment had significantly lesser numbers of conversions (OR 0.09 (0.03-0.32); p < 0.0005) and other complications (SSI and anastomic leakage excluded) (OR 0.32 (0.15-0.69); p = 0.004), adjusted for potential confounders. CONCLUSIONS: Our study suggests that robotic surgery in the hands of experienced laparoscopic rectal cancer surgeons improves the conversion rate and complication rate drastically compared to conventional laparoscopic surgery, but operation time is longer.

Robot-assisted laparoscopic resection of clinical T4b tumours of distal sigmoid and rectum: initial results.

BACKGROUND: Radical resection by multivisceral resection of colorectal T4 tumours is important to reduce local recurrence and improve survival. Oncological safety of laparoscopic resection of T4 tumours is controversial. However, robot-assisted resections might have advantages, such as 3D view and greater range of motion of instruments. The aim of this study is to evaluate the initial results of robot-assisted resection of T4 rectal and distal sigmoid tumours. METHODS: This is a cohort study of a prospectively kept database of all robot-assisted rectal and sigmoid resections between 2012 and 2017. Patients who underwent a multivisceral resection for tumours appearing as T4 cancer during surgery were included. Rectal and sigmoid resections are routinely performed with the DaVinci robot, unless an indication for intra-operative radiotherapy exists. RESULTS: 28 patients with suspected T4 rectal or sigmoid cancer were included. Most patients (78%) were treated with neoadjuvant chemoradiotherapy (n = 19), short course radiotherapy with long waiting interval (n = 2) or chemotherapy (n = 1). En bloc resection was performed with the complete or part of the invaded organ (prostate, vesicles, bladder, abdominal wall, presacral fascia, vagina, uterus, adnex). In 3 patients (11%), the procedure was converted to laparotomy. Twenty-four R0-resections were performed (86%) and four R1-resections (14%). Median length of surgery was 274 min (IQR 222-354). Median length of stay was 6 days (IQR 5-11). Twelve patients (43%) had postoperative complications: eight (29%) minor complications and four (14%) major complications. There was no postoperative mortality. CONCLUSIONS: Robot-assisted laparoscopy seems to be a feasible option for the resection of clinical T4 cancer of the distal sigmoid and rectum in selected cases. Radical resections can be achieved in the majority of cases. Therefore, T4 tumours should not be regarded as a strict contraindication for robot-assisted surgery.

What is the Risk of Colorectal Cancer After an Episode of Acute Diverticulitis in Conservatively Treated Patients?

GOALS: The goal is to find the risk of colorectal cancer after an episode of acute diverticulitis in conservatively treated patients. Secondly, to determine the benefit of colonoscopy in these patients. BACKGROUND: In the Netherlands, it is a common practice to routinely perform a colonoscopy after an episode of conservatively treated diverticulitis to exclude a malignancy. Yet according to the Dutch guidelines, these patients should not undergo a colonoscopy on a routine basis. The aim of this study is to determine the benefit of a colonoscopy in patients who have been treated for diverticulitis conservatively. STUDY: This retrospective study includes patients who were diagnosed with acute diverticulitis (Hinchey 0 and I) and were treated conservatively, with or without antibiotics. Only patients who underwent colonoscopy were included for analysis. In addition, the outcome (yes or no colorectal cancer) of colonoscopy was analyzed according to patients' presentation of alarm symptoms for colorectal cancer. RESULTS: Between January 2008 and June 2013, 977 patients were treated conservatively for an episode of acute diverticulitis. Of those, 645 underwent colonoscopy during follow-up. Alarm symptoms for colorectal cancer were present in 205 patients. Nine of them were diagnosed with colorectal cancer (4.4%) versus 1 patient (0.2%, P=0.0002) in the group without alarm symptoms (N=440). CONCLUSIONS: This study confirms that routine colonoscopy is not indicated after acute diverticulitis which has been treated conservatively in a large series. Only in case of alarm symptoms a colonoscopy is mandatory, but even then the actual finding of a colorectal cancer is rare.

Sexual, marital, and general life functioning in couples coping with colorectal cancer: a dyadic study across time.

OBJECTIVES: This study evaluated the following: (a) levels of sexual, marital, and general life functioning for both patients and partners; (b) interdependence between both members of the couple; and (c) longitudinal change in sexual, marital, and general life functioning and longitudinal stress-spillover effects in these three domains from a dyadic perspective. METHODS: Couples (n = 102) completed the Maudsley Marital Questionnaire preoperatively and 3 and 6 months postoperatively. Mean scores were compared with norm scores. A multivariate general linear model and a multivariate latent difference score - structural equation modeling (LDS-SEM), which took into account actor and partner effects, were evaluated. RESULTS: Patients and partners reported lower sexual, mostly similar marital, and higher general life functioning compared with norm scores. Moderate to high within-dyad associations were found. The LDS-SEM model mostly showed actor effects. Yet the longitudinal change in the partners' sexual functioning was determined not only by their own preoperative sexual functioning but also by that of the patient. Preoperative sexual functioning did not spill over to the other two domains for patients and partners, whereas the patients' preoperative general life functioning influenced postoperative change in marital and sexual functioning. Health care professionals should examine potential sexual problems but have to be aware that these problems may not spill over to the marital and general life domains. In contrast, low functioning in the general life domain may spill over to the marital and sexual domains. The interdependence between patients and partners implies that a couple-based perspective (e.g., couple-based interventions/therapies) to coping with cancer is needed.

Effect of a comprehensive surgical safety system on patient outcomes.

BACKGROUND: Adverse events in patients who have undergone surgery constitute a large proportion of iatrogenic illnesses. Most surgical safety interventions have focused on the operating room. Since more than half of all surgical errors occur outside the operating room, it is likely that a more substantial improvement in outcomes can be achieved by targeting the entire surgical pathway. METHODS: We examined the effects on patient outcomes of a comprehensive, multidisciplinary surgical safety checklist, including items such as medication, marking of the operative side, and use of postoperative instructions. The checklist was implemented in six hospitals with high standards of care. All complications occurring during admission were documented prospectively. We compared the rate of complications during a baseline period of 3 months with the rate during a 3-month period after implementation of the checklist, while accounting for potential confounders. Similar data were collected from a control group of five hospitals. RESULTS: In a comparison of 3760 patients observed before implementation of the checklist with 3820 patients observed after implementation, the total number of complications per 100 patients decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7) to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction of 10.6 (95% CI, 8.7 to 12.4). The proportion of patients with one or more complications decreased from 15.4% to 10.6% (P<0.001). In-hospital mortality decreased from 1.5% (95% CI, 1.2 to 2.0) to 0.8% (95% CI, 0.6 to 1.1), for an absolute risk reduction of 0.7 percentage points (95% CI, 0.2 to 1.2). Outcomes did not change in the control hospitals. CONCLUSIONS: Implementation of this comprehensive checklist was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care. (Netherlands Trial Register number, NTR1943.).

Postponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study.

BACKGROUND: Right-sided obstructing colon cancer is most often treated with acute resection. Recent studies on right-sided obstructing colon cancer report higher mortality and morbidity rates than those in patients without obstruction. The aim of this study is to retrospectively analyse whether it is possible to optimise the health condition of patients with acute right-sided obstructing colon cancer, prior to surgery, and whether this improves postoperative outcomes. METHOD: All consecutive patients with high suspicion of, or histologically proven, right-sided obstructing colon cancer, treated with curative intent between March 2013 and December 2019, were analysed retrospectively. Patients were divided into two groups: optimised group and non-optimised group. Pre-operative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression. RESULTS: In total, 54 patients were analysed in this study. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. Scheduled surgery was performed after a median of eight days (IQR 7-12). Postoperative complications were found in twelve (50%) patients in the optimised group, compared to twenty-three (77%) patients in the non-optimised group (p = 0.051). Major complications were diagnosed in three (13%) patients with optimisation, compared to ten (33%) patients without optimisation (p = 0.111). Postoperative in-hospital stay, 30-day mortality, as well as primary anastomosis were comparable in both groups. CONCLUSION: This pilot study suggests that pre-operative optimisation of patients with obstructing right sided colonic cancer may be feasible and safe but is associated with longer in-patient stay.

Comparison of three-year oncological results after restorative low anterior resection, non-restorative low anterior resection and abdominoperineal resection for rectal cancer.

INTRODUCTION: Oncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR). MATERIALS AND METHODS: This retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate. RESULTS: Of 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001. CONCLUSION: NRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.