Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England.

OBJECTIVE: To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. SUMMARY OF BACKGROUND DATA: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. METHODS: We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. RESULTS: One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. CONCLUSIONS: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.

Is 3D faster and safer than 4K laparoscopic cholecystectomy? A randomised-controlled trial.

BACKGROUND: Laparoscopic surgery has well-established benefits for patients; however, laparoscopic procedures have a long and difficult learning curve, in large part due to the lack of stereoscopic depth perception. Developments in high-definition and stereoscopic imaging have attempted to overcome this. Three-dimensional high-definition (3D HD) systems are thought to improve operating times compared to two-dimensional high-definition systems. However their performance against new, ultra-high-definition ('4K') systems is not known. METHODS: Patients undergoing laparoscopic cholecystectomy were randomised to 3D HD or 4K laparoscopy. Operative videos were recorded, and the time from gallbladder exposure to separation from the liver (minus on table cholangiogram) was calculated. Blinded video assessment was performed to calculate intraoperative error scores. RESULTS: One hundred and twenty patients were randomised, of which 109 were analysed (3D HD n = 54; 4K n = 55). No reduction in operative time was detected with 3D HD compared to 4K laparoscopy (median [IQR]; 23.41 min [17.00-37.98] vs 20.90 min [17.67-33.03]; p = 0.91); nor was there any decrease observed in error scores (60 [56-62] vs 58 [56-60]; p = 0.27), complications or reattendance. Stone spillage occurred more frequently with 3D HD, but there were no other differences in individual error rates. Gallbladder grade and operating surgeon had significant effects on time to complete the operation. Gallbladder grade also had a significant effect on the error score. CONCLUSIONS: A 3D HD laparoscopic system did not reduce operative time or error scores during laparoscopic cholecystectomy compared with a new 4K imaging system.

Laparoscopic Surgery for Severe Rectovaginal Endometriosis Compromising the Bowel: A Prospective Cohort Study.

STUDY OBJECTIVE: Endometriosis can affect 10% of women at reproductive age. Of those, 5.3% to 12% will have endometriosis affecting the bowel. Although outcomes after surgery for severe endometriosis affecting the bowel have previously been studied and have shown improvement in generic quality of life indices and sexual function, few studies have evaluated bowel function or symptoms specific to endometriosis. Our aim was to determine the quality of life after radical excision of rectovagina endometriosis compromising the bowel. DESIGN: Single-center prospective cohort study (Canadian Task Force classification II-2). SETTING: Specialist referral center for the management of advanced endometriosis. PATIENTS: Women with severe rectovaginal endometriosis compromising the bowel. INTERVENTIONS: Comparison of preoperative data with a 2-, 6-, and 12-month follow-up was made for consecutive patients who underwent surgery for endometriosis with bowel involvement. The main outcome measures were quality of life using the Endometriosis Health Profile 30 and EuroQol-5 dimension questionnaires. Bowel symptoms were measured using the Gastrointestinal Quality of Life Index. Dysmenorrhea, dyspareunia, dyschezia, and chronic pain were measured using a visual analogue scale. To compare preoperative and postoperative scores, a Freidman test was performed followed by a preoperative and 12-month postoperative Wilcoxon signed-rank test. A Mann-Whitney U test was used to compare the results between those who had pelvic clearance and those who did not. MEASUREMENTS AND MAIN RESULTS: In total, 137 patients had surgery, of which 100 completed follow-up to 12 months. The serious perioperative and postoperative complication rate was 7.3%. The results show significant improvement in almost all variables measured (p < .01). At 12 months patients who had a pelvic clearance (hysterectomy with bilateral salpingo-oophorectomy) had significantly less pain with better bowel function. Additionally, they had higher quality of life scores and greater satisfaction with their treatment. There was no significant difference between any postoperative variables tested regardless of the type of bowel surgery. CONCLUSION: Severe rectovaginal endometriosis compromising the bowel can be treated surgically with experienced combined gynecologic and colorectal input with a low serious complication rate. Surgery by an experienced multidisciplinary team results in significant improvement in pain, sexual function, and quality of life up to 1 year postoperatively. Pelvic clearance improves outcome and patients should be counseled accordingly. There is no difference in outcome between the types of bowel surgery undertaken as long as all visible/palpable endometriosis is removed.

Gastrointestinal Permeability After Bariatric Surgery: A Systematic Review.

Gastrointestinal permeability refers to the movement of substances across the gut wall. This is mediated by endotoxemia (bacterial products entering the systemic circulation), and is associated with metabolic disease. The effect of bariatric surgery on permeability remains uncertain; the associated dietary, metabolic and weight changes are suggested to influence, or trigger, altered permeability. The primary aim of this study is to synthesize evidence and analyze the effect of bariatric surgery on permeability. A systematic review was performed, searching MEDLINE, EMBASE, and Scopus until February 2023, using MESH terms "intestinal permeability", "bariatric", for studies reporting in vivo assessment of permeability. Three cohort studies and two case series were identified (n=96). Data was heterogeneous; methodology and controls preclude meta-analysis. Gastroduodenal permeability reduced post-sleeve gastrectomy (SG). Two studies showed an increase in small intestinal permeability after biliopancreatic diversion. Two studies revealed a decrease in post-Roux-en-Y gastric bypass. One study identified increased colonic permeability six months post-SG. Evidence regarding permeability change after bariatric surgery is conflicting, notably for the small intestine. Impaired colonic permeability post-SG raises concerns regarding colonic protein fermentation and harmful dietary sequelae. There are multiple interacting variables confounding gastrointestinal permeability change; procedure type, altered microbiota and metabolic response to surgery. Further understanding of this important aspect of obesity is required, both before and after bariatric surgery.

Survival following laparoscopic and open colorectal surgery.

BACKGROUND: Laparoscopic colorectal surgery is known to provide increased benefits to patients during the postoperative recovery period. Initial scepticism over the oncological adequacy of resection has been dismissed by a number of major randomized trials. Emerging evidence indicates that laparoscopic surgery may provide a potential survival benefit in colorectal cancer. METHODS: Patients undergoing elective laparoscopic or open resection for colorectal cancer between October 2003 and December 2010 were analyzed. Data were collated and a database compiled. Survival analysis was calculated by using the Kaplan-Meier method. RESULTS: A total of 665 resections were performed with 457 laparoscopically and 208 open. The median length of stay was 4 days following laparoscopic resection and 7 days following open (p < 0.0005). There was no significant difference between the two groups apart from gender (p = 0.03), ASA (p = 0.03), and the number of patients with extranodal metastatic disease (p = 0.01). The 5-year overall survival (OS) in the completed laparoscopic group was 75.8 versus 72.5 % in the open group (p = 0.12). The 5-year OS in patients who were converted was 52 %. The 5-year OS for nonmetastatic disease in the completed laparoscopic group was significantly greater at 79.4 versus 74 % in the open group (p = 0.03). There was no difference between the groups in OS for rectal cancer (p = 0.66), but there was an OS advantage for laparoscopically resected colon cancer (p = 0.02). CONCLUSIONS: Laparoscopic resection for nonmetastatic colon cancer may provide an overall survival advantage.

Replicate and repeat faecal immunochemical tests in symptomatic patients: A systematic review.

BACKGROUND: Faecal Immunochemical tests (FITs) in the assessment of patients presenting with symptoms have generally used a single sample. Little evidence pertains to the use of replicate, where a number of tests are done prior to decision-making or repeat FIT, where additional FIT are performed following clinical decision-making. Overwhelmingly, research has focussed on FIT to help identify colorectal cancer (CRC). The aim of this review is to assess the available literature concerning replicate and repeat FIT in symptomatic patients to help generate consensus and guide future research. METHODS: The terms 'faecal immunochemical test' or 'FIT' were combined with 'multiple' or 'repeat'. EMBASE, Medline and PubMed database and other searches were conducted. All papers published in English were included with no exclusion date limits until November 2021. RESULTS: Of the 161 initial papers screened, seven were included for review. Qualitative and quantitative FIT outcomes were assessed in the studies. The primary aims of most related to whether replicate FIT increased diagnostic yield of CRC, with colonoscopy used as the reference standard. One publication assessed the impact of a new COVID-adapted pathway on CRC detection. No consensus on replicate FIT was apparent. Some concluded that FITs may help minimise missed CRC diagnoses: others showed no increase in diagnostic yield of CRC. CONCLUSIONS: Current evidence on replicate and repeat FIT is both minimal and conflicting. FIT is a superb clinical tool, but significant gaps surrounding application remain. Further studies relating to replicate and repeat FIT are required.

An observational study of replicate faecal immunochemical tests in the urgently referred symptomatic cohort.

INTRODUCTION: Triage of patients with suspected colorectal cancer (CRC) utilises a single faecal immunochemical test (FIT) at a defined threshold. Limited evidence exists regarding whether replicate FIT improves the positive and negative predictive value in symptomatic patients. This study examines urgently referred symptomatic patients undergoing replicate FIT. Primary aim is to assess two FITs and CRC/serious bowel disease. Secondary aims are to determine correlation and utility of replicate FIT. METHODOLOGY: Patients carried out one additional FIT during COVID-19 pandemic. FIT 1 and FIT 2 (the replicate sample) were analysed in relation to symptoms, diagnoses, investigations, future colonoscopy and missed CRC. Study period was 01/03/2020-31/07/2020. Three subgroups were compared; double positive (≥10 µg Hb/g faeces), double negative, and discordant FIT (one positive). RESULTS: 111 patients had replicate FIT (50 male, 61 female). 43 (38.7%) patients had double negative, 32 (28.8%) double positive and 36 (32.4%) had discordant FITs. Median time between FITs was 14 days (IQR = 11-19). 83% of double positive patients underwent colonoscopy/virtual colonoscopy (61% in double negative patients). Six CRC and one high-risk polyp were in double positive patients (none in other groups). One discordant patient was not investigated and a CRC missed. CONCLUSIONS: Replicate FIT as a triage strategy appears most effective where both FITs are negative. CRC risk is low when FIT results are discordant. Double negative FITs are reassuring given benign associated diagnoses, or for patients where endoscopic investigation is high-risk. Larger studies are required to evaluate discordant FITs, enabling refinement of urgent investigation pathways.

Planned organ preservation for elderly patients with rectal cancer using short course radiotherapy and a contact brachytherapy boost-an International multi-institution analysis.

Background and purpose: The use of external beam radiotherapy (EBRT) and contact X-Ray brachytherapy (CXB) is emerging as an effective alternative in patients with early stage rectal cancer with the intent of organ preservation (OP). Short course radiotherapy (SCRT) is an alternative EBRT schedule for patients not fit for chemotherapy or for longer courses of EBRT. There are no multicentre studies that have reported on the outcomes of SCRT with a CXB boost, therefore we present these from patients from centres from the UK and Sweden. Materials and methods: From the Guildford Colorectal Database or local databases, 258 patients who underwent SCRT and CXB with the intent of OP from five centres treated between 2007 and 2019 were identified. Response and survival data was analysed and presented. Results: With a median age of 81, 226 patients were treated with radiotherapy alone (RTA) and 32 immediately after local excision (ILE). Median follow-up was 24 months. 70% and 97% of patients in the RTA and ILE groups respectively had a complete clinical response (cCR) after SCRT with CXB. Of those, local relapse was seen in 16% of the RTA and 3% of the ILE group. Median survival was 40 months after CXB in the RTA and 52 months in the ILE group. 94% of patients remained stoma-free to the point of latest follow-up. Conclusion: This data suggests that CXB when combined with SCRT, in a mainly elderly and comorbid population, provides good palliation with stoma-avoidance. Oncological outcomes compare with previously published work. A greater focus is required on quality of life outcomes after OP.

GEC ESTRO ACROP consensus recommendations for contact brachytherapy for rectal cancer.

PURPOSE: To issue consensus recommendations for contact X-Ray brachytherapy (CXB) for rectal cancer covering pre-treatment evaluation, treatment, dosimetric issues and follow-up. These recommendations cover CXB in the definitive and palliative setting. METHODS: Members of GEC ESTRO with expertise in rectal CXB issued consensus-based recommendations for CXB based on literature review and clinical experience. Levels of evidence according to the Oxford Centre for Evidence based medicine guidance are presented where possible. RESULTS: The GEC ESTRO ACROP consensus recommendations support the use of CXB to increase the chances of clinical complete remission and cure for patients who are elderly with high surgical risk, surgically unfit or refusing surgery. For palliative treatment, the use of CXB is recommended for symptomatic relief and disease control. The use of CXB in an organ-preservation setting in surgically fit patients is recommended within the setting of a clinical trial or registry. CONCLUSIONS: The GEC ESTRO ACROP recommendations for CXB are provided. Recommendations towards standardisation of reporting and prescription are given. Practitioners are encouraged to follow these recommendations and to develop further clinical trials to examine this treatment modality and increase the evidence base for its use. The routine collection of outcomes both clinical and patient-reported is also encouraged.

Colorectal cancer detection by measuring DNA from exfoliated colonocytes obtained by direct contact with rectal mucosa.

The purpose of the study was to explore the potential of direct exfoliated colonocyte collection from human rectal mucosa for colorectal cancer screening. A special device was designed for standardized collection of exfoliated cells from the surface of human rectal mucosa. Material was collected from 120 outpatients selected for colonoscopy and 36 patients with confirmed diagnosis of colorectal cancer or large polyps. Determination of total DNA amounts in the collected samples (DNA scores) by PicoGreen assay and real-time PCR was employed alongside cytological assessment. Well preserved cells with cytological patterns characteristic for different colorectal conditions (cancer, inflammatory bowel disease) were detected in the collected material. In the outpatient group DNA scores were higher in patients with cancer and inflammatory bowel disease compared to those with no abnormalities detected, diverticular disease and small polyps (P<0.001 for PicoGreen assay; P=0.002 for real-time PCR). The sensitivity and specificity of the quantitative DNA test (PicoGreen assay; cut-off point 3.0 microg/ml) for detecting serious colorectal conditions were 1.00 and 0.74, respectively. In the group with confirmed tumours, the PicoGreen assay performed better for distal colorectal cancer (sensitivity 0.83; specificity 0.76) compared with proximal colon malignancies (sensitivity 0.57; specificity 0.76). It can be concluded that the proposed technique of direct collection of exfoliated cells from the surface of human rectal mucosa provides abundant cellular material suitable for diagnostic and research applications. Further refinement of the quantitative DNA test may lead to a new approach for colorectal cancer early detection and screening.

Radiological and clinical findings following rectal contact X-ray brachytherapy (Papillon technique) - how to assess response.

PURPOSE: Rectal contact X-ray brachytherapy (Papillon radiotherapy) has recently received approval from the National Institute for Health and Care Excellence. In particular, it is suitable for elderly patients who are high-risk for a major operation, but it may also be undertaken for patients who wish to avoid a stoma. It is imperative to be able to identify clinical response or tumor regrowth on surveillance magnetic resonance imaging (MRI) and sigmoidoscopy. This article aims to help clinicians to interpret MRIs and endoscopic appearances following Papillon radiotherapy. MATERIAL AND METHODS: MRI and sigmoidoscopy images are presented from a case series of seven non-consecutive, heterogeneously treated patients with T2 to 3C N0 rectal adenocarcinoma. Treatments included transanal excision, adjuvant or neoadjuvant chemo/radiotherapy, and Papillon radiotherapy. These patients wished to avoid a stoma or were high-risk for a major operation. These cases have been chosen to demonstrate response assessment alone. RESULTS: The "black spider" sign of maturing, low signal fibrosis on MRI was found to be reassuring, as was the presence of a flat scar on endoscopy. Residual tumor mass or intermediate signal suggest equivocal response, which may necessitate transanal excision. Loss of low signal fibrosis, or the development of soft tissue nodularity or mass should prompt biopsy. CONCLUSIONS: MR scans should be used in combination with endoluminal mucosal assessment (and digital rectal examination) to determine response following Papillon radiotherapy. This is the first paper to describe both the endoscopic and imaging findings following Papillon radiotherapy.

Large-Vessel Sealing in Laparoscopic Colectomy with an Ultrasonic Device.

BACKGROUND AND OBJECTIVE: The Harmonic ACE+7 Shears with Advanced Hemostasis Mode (Ethicon, Somerville, NJ, USA) is an ultrasonic device designed to transect and seal vessels up to 7 mm in diameter. The device applies an algorithm that optimizes ultrasonic energy delivery combined with a longer sealing cycle. The purpose of this study was to assess the initial clinical experience with the Harmonic device by evaluating large-vessel sealing during laparoscopic colectomy in consecutive cases. METHODS: This prospective, multicenter, observational series involved 40 adult patients who were to undergo elective laparoscopic colectomy where dissection and transection of the inferior mesenteric artery was indicated. The primary study endpoint was first-pass hemostasis, defined as a single activation of the Advanced Hemostasis Mode to transect and seal the inferior mesenteric artery. The use of any additional energy device or hemostatic product to establish or maintain hemostasis was noted. Patients were observed after surgery for ∼4 weeks for adverse events that were considered to be related to the study procedure or study device. Descriptive statistical analyses were performed for study endpoints. RESULTS: Forty patients underwent the laparoscopic colectomy procedure. First-pass hemostasis of the inferior mesenteric artery was achieved and maintained in all 40 patients, with no required additional hemostatic measures. Exposure of the vessel was reported as skeletonized in 22 of 40 (55%) patients. Mean transection time was 21.9 ± 7.4 s. One adverse event (postoperative anemia) was considered possibly related to the study device. CONCLUSION: In this initial clinical consecutive series, the device demonstrated successful transection and sealing of the large mesenteric vessels during laparoscopic colorectal surgery.

Robot-assisted laparoscopic Heller's cardiomyotomy.

There are many options available for the management of achalasia. Recently, the list of options has expanded to include robotic-assisted Heller's cardiomyotomy. In this article, we describe the procedure for a robotic-assisted cardiomyotomy and discuss the advantages of using a robotic, master-slave system.

Laparoscopic TME for rectal cancer: a case series.

PURPOSE: Laparoscopic colonic resection for cancer is becoming well established within the surgical community. However, the current evidence for laparoscopic total mesorectal excision (TME) is scanty but does point toward a potential for improved short-term outcomes and oncological equivalency to open resection. METHODS: Patients undergoing laparoscopic TME for rectal cancer in 1 hospital between October 2003 and December 2010 were analyzed. Data were collated from a prospective database. Survival analysis was calculated using the Kaplan-Meier method. RESULTS: 79 patients were analyzed (96.3% of all TMEs). There was a median length of stay of 5 days, with no postoperative mortality. The 5-year overall survival was 70% and the 5-year disease-free survival was 65.5%. There was a conversion rate of 10.1%. The 5-year overall survival for completed laparoscopic cases was 70.6% versus 62.5% for converted cases (P=0.041). CONCLUSIONS: There seems to be increasing evidence that laparoscopic TME is equivalent to open TME for rectal cancer. Conversion may be deleterious to overall survival.

Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial.

PURPOSE: A prospective trial was conducted to establish long-term healing of complex idiopathic anorectal fistula, without extension, after fibrin glue treatment, with clinical assessment and magnetic resonance imaging to determine tract healing. METHODS: Twenty-two patients undergoing glue instillation after fistula curettage and irrigation were followed up for a median of 14 months. Clinical assessment, short tau inversion recovery sequence magnetic resonance imaging, and combined short tau inversion recovery and dynamic contrast-enhanced magnetic resonance imaging were performed at a median of three months postoperatively, and their ability to predict outcome in the presence of early skin healing was determined. RESULTS: Of 22 patients, 19 (86.5 percent) had transsphincteric fistulas, 1 (4.5 percent) had a suprasphincteric fistula, 1 (4.5 percent) had an extrasphincteric fistula, and 1 (4.5 percent) had a rectovaginal fistula. None had clinical or radiologic evidence of secondary extension. Despite skin healing in 17 (77 percent) of 22 patients at a median of 14 days after treatment, only 3 (14 percent) remained healed at 16 months. Magnetic resonance imaging with short tau inversion recovery sequences in combination with dynamic contrast-enhanced magnetic resonance imaging predicted outcome in all 10 assessments (100 percent), compared with short tau inversion recovery sequence alone in 16 (94 percent) of 17 assessments or clinical examination in 12 (71 percent) of 17 (P = 0.02). CONCLUSIONS: The success rate of fibrin glue application for complex anorectal fistulas without extension is 14 percent. Magnetic resonance imaging predicts outcome at an earlier stage than clinical examination.