An Observational Analysis of a Novel Digital Rectoscope.

BACKGROUND: This is an analysis of the first 50 in-human uses of a novel digital rigid sigmoidoscope. The technology provides digital image capture, telemedicine capabilities, improved ergonomics, and the ability to biopsy under pneumorectum while maintaining the low cost of conventional rigid sigmoidoscopy. The primary outcome was adverse events, and the secondary outcome was diagnostic view. PRELIMINARY RESULTS: Fifty patients underwent outpatient (n = 25) and surgical rectal assessment (n = 25), with a mean age of 60 years. This included 31 men and 19 women with 12 different clinical use indications. No adverse events were reported, and no defects were reported with the instrumentation. Satisfactory diagnoses were obtained in 48 (96%) of 50 uses, images were captured in 48 (96%) of 50 uses, and biopsies were successfully taken in 13 uses (26%). No adverse events were recorded. Independent reviewers of recorded videos agreed on the quality and diagnostic value of the images with a κ of 0.225 (95% CI, 0.144-0.305) when assessing whether the target pathology was adequately visualized. IMPACT OF INNOVATION: The improved views afforded by digital rectoscopy facilitated a satisfactory clinical diagnosis in 96% of uses. The device was successfully deployed in the operating room and outpatients irrespective of bowel preparation method, where it has the potential to replace flexible sigmoidoscopy for specific use cases. The technology provides a high-quality image and video that can be securely recorded for documentation and medicolegal purposes with agreement between blinded users despite a lack of standardized training and heterogenous pathology. We perceive significant impact of this technology for the assessment of colorectal anastomoses, the office management of colitis, "watch and wait," and for diagnostic support in rectal cancer diagnosis. The technology has significant potential to facilitate proctoring and training, and it now requires prospective trials to validate its diagnostic accuracy against more costly flexible sigmoidoscopy systems.

Minimal access rectal cancer surgery: an observational study of patient outcomes from a district general hospital with over a decade of experience with robotic rectal cancer surgery.

AIM: Robotic surgery for colorectal cancer has become established more slowly than in other specialities. The aim of this study was to assess the risks and benefits of the use of robotic rectal cancer surgery in comparison with laparoscopic surgery within the confines of a subspecialist rectal cancer service in a district general hospital. METHOD: Outcomes from consecutive patients undergoing minimal access rectal cancer surgery between July 2008 and January 2020 were analysed. Comparisons were made between short-term outcomes including conversion rates, anastomotic leakage and pathological outcomes as well as long-term survival and cancer recurrence. RESULTS: A total of 337 patients were included in the analysis, 204 (60.5%) of whom underwent robotic surgery. Demographic characteristics and use of neoadjuvant chemoradiotherapy were similar between groups. However, patients having robotic surgery had significantly lower tumours than in the laparoscopic group (7.6 cm vs. 9.8 cm, p = 0.003). Conversion to open surgery in the robotic group was significantly less likely (9.8% vs. 22.6%, p = 0.001). Operative mortality, clinical leakage and major complications were similar between groups. While asymptomatic 'radiological' leaks were significantly more common following robotic surgery (13.7% vs. 5.3%, p = 0.017) this did not affect the long-term stoma closure rate. Pathological outcomes were similar with the exception of shorter mean distal resection margins (25.9 mm vs. 32.8 mm, p = 0.001) for the robotic group of patients. There was no statistical difference in 5-year survival between groups (78.7% robotic vs. 85.4% laparoscopic, p = 0.263) nor local recurrence (2.0% robotic vs. 3.8% laparoscopic, p = 0.253). CONCLUSIONS: These results illustrate how the selective use of robotic surgery by a dedicated rectal cancer team can achieve low rates of cancer recurrence and low permanent stoma rates.

Preclinical evaluation of the versius surgical system, a new robot-assisted surgical device for use in minimal access general and colorectal procedures.

OBJECTIVE: To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting. Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots. METHODS: Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device's safety in performing cholecystectomy or small bowel enterotomy. RESULTS: Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons' preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications. CONCLUSIONS: This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.

The 'hub and spoke model' for the management of surgical patients during the COVID-19 pandemic.

During the on-going COVID-19 pandemic a number of key public health services have been severely impacted. These include elective surgical services due to the synergetic resources required to provide both perioperative surgical care whilst also treating acute COVID-19 patients and also the poor outcomes associated with surgical patients who develop COVID-19 in the perioperative period. This article discusses the important principles and concepts for providing important surgical services during the COVID-19 pandemic based on the model of the RMCancerSurgHub which is providing surgical cancer services for a population of approximately 2 million people across London during the pandemic. The model focusses on creating local and regional hub centres which provide urgent treatment for surgical patients in an environment that is relatively protected from the burden of COVID-19 illness. The model extensively utilises the extended multidisciplinary team to allow for a flexible approach with core services delivered in 'clean' sites which can adapt to viral surges. A key requirement is that of a clinical prioritisation process which allows for equity in access within and between specialties ensuring that patients are treated on the basis of greatest need, while at the same time protecting those whose conditions can safely wait from exposure to the virus. Importantly, this model has the ability to scale-up activity and lead units and networks into the recovery phase. The model discussed is also broadly applicable to providing surgical services during any viral pandemic.

Hand-Sewn versus Stapled Closure of Loop Ileostomy: A Meta-Analysis.

BACKGROUND: Individual trials comparing hand-sewn with stapled closure of loop ileostomy show different outcomes due to lack of statistical power. A systematic review, with a pooled analysis of results, might provide a more definitive answer. This review aimed to compare hand-sewn with stapled anastomotic technique for closure of a loop ileostomy and looked at the effect of bowel resection on the complication rates. METHODOLOGY: Relevant studies were identified from MEDLINE, EMBASE and the Cochrane database. All randomised clinical trials, prospective and retrospective studies comparing hand-sewn with stapled closure of loop ileostomy were included. RESULTS: Of the 4,917 patients in 15 identified studies, 3,406 had hand-sewn and 1,511 stapled anastomosis. There was no difference in the rate of anastomotic leak between the hand-sewn (2.93%, 55/1,877) and the stapled group (2.08%, 25/1,202) (OR 0.81, 95% CI 0.43-1.54, p = 0.52, I2 = 33%). The rate of small-bowel obstruction was higher in the hand-sewn group (7.03%, 231/3,284) compared to the stapled group (5.58%, 73/1,308; OR 0.69, 95% CI 0.51-0.92, p = 0.01, I2 = 0%). There was no difference in the incidence of anastomotic leak and small-bowel obstruction in the hand-sewn anastomosis between patients with or without bowel resection. CONCLUSIONS: There was no significant difference in the rate of anastomotic leakage between the hand-sewn and stapled techniques. The rate of small-bowel obstruction was higher in the hand-sewn group. Performance of bowel resection does not significantly increase the incidence of anastomotic leak or small-bowel obstruction.

Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial.

Importance: Robotic rectal cancer surgery is gaining popularity, but limited data are available regarding safety and efficacy. Objective: To compare robotic-assisted vs conventional laparoscopic surgery for risk of conversion to open laparotomy among patients undergoing resection for rectal cancer. Design, Setting, and Participants: Randomized clinical trial comparing robotic-assisted vs conventional laparoscopic surgery among 471 patients with rectal adenocarcinoma suitable for curative resection conducted at 29 sites across 10 countries, including 40 surgeons. Recruitment of patients was from January 7, 2011, to September 30, 2014, follow-up was conducted at 30 days and 6 months, and final follow-up was on June 16, 2015. Interventions: Patients were randomized to robotic-assisted (n = 237) or conventional (n = 234) laparoscopic rectal cancer resection, performed by either high (upper rectum) or low (total rectum) anterior resection or abdominoperineal resection (rectum and perineum). Main Outcomes and Measures: The primary outcome was conversion to open laparotomy. Secondary end points included intraoperative and postoperative complications, circumferential resection margin positivity (CRM+) and other pathological outcomes, quality of life (36-Item Short Form Survey and 20-item Multidimensional Fatigue Inventory), bladder and sexual dysfunction (International Prostate Symptom Score, International Index of Erectile Function, and Female Sexual Function Index), and oncological outcomes. Results: Among 471 randomized patients (mean [SD] age, 64.9 [11.0] years; 320 [67.9%] men), 466 (98.9%) completed the study. The overall rate of conversion to open laparotomy was 10.1%: 19 of 236 patients (8.1%) in the robotic-assisted laparoscopic group and 28 of 230 patients (12.2%) in the conventional laparoscopic group (unadjusted risk difference = 4.1% [95% CI, -1.4% to 9.6%]; adjusted odds ratio = 0.61 [95% CI, 0.31 to 1.21]; P = .16). The overall CRM+ rate was 5.7%; CRM+ occurred in 14 (6.3%) of 224 patients in the conventional laparoscopic group and 12 (5.1%) of 235 patients in the robotic-assisted laparoscopic group (unadjusted risk difference = 1.1% [95% CI, -3.1% to 5.4%]; adjusted odds ratio = 0.78 [95% CI, 0.35 to 1.76]; P = .56). Of the other 8 reported prespecified secondary end points, including intraoperative complications, postoperative complications, plane of surgery, 30-day mortality, bladder dysfunction, and sexual dysfunction, none showed a statistically significant difference between groups. Conclusions and Relevance: Among patients with rectal adenocarcinoma suitable for curative resection, robotic-assisted laparoscopic surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy. These findings suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection. Trial Registration: isrctn.org Identifier: ISRCTN80500123.

Sarcopenia is independently associated with poor preoperative physical fitness in patients undergoing colorectal cancer surgery.

BACKGROUND: Accurate preoperative risk assessment for major colorectal cancer (CRC) surgery remains challenging. Body composition (BC) and cardiopulmonary exercise testing (CPET) can be used to evaluate risk. The relationship between BC and CPET in patients undergoing curative CRC surgery is unclear. METHODS: Consecutive patients undergoing CPET prior to CRC surgery between 2010 and 2020 were identified between two different UK hospitals. Body composition phenotypes such as sarcopenia, myosteatosis, and visceral obesity were defined using widely accepted thresholds using preoperative single axial slice CT image at L3 vertebrae. Relationships between clinicopathological, BC, and CPET variables were investigated using linear regression analysis. RESULTS: Two hundred eighteen patients with stage I-III CRC were included. The prevalence of sarcopenia, myosteatosis, and visceral obesity was 62%, 33%, and 64%, respectively. The median oxygen uptake at anaerobic threshold (VO2 at AT) was 12.2 mL/kg/min (IQR 10.6-14.2), and oxygen uptake at peak exercise (VO2 peak) was 18.8 mL/kg/min (IQR 15.4-23). On univariate linear regression analysis, male sex (P < 0.001) was positively associated with VO2 at AT. While ASA grade (P < 0.001) and BMI (P = 0.007) were negatively associated with VO2 at AT, on multivariate linear regression analysis, these variables remained significant (P < 0.05). On univariate linear regression analysis, male sex (P < 0.001) was positively associated with VO2 peak, whereas age (P < 0.001), ASA grade (P < 0.001), BMI (P = 0.003), sarcopenia (P = 0.015), and myosteatosis (P < 0.001) were negatively associated with VO2 peak. On multivariate linear regression analysis age (P < 0.001), ASA grade (P < 0.001), BMI (P < 0.001), and sarcopenia (P = 0.006) were independently and negatively associated with VO2 peak. CONCLUSIONS: The novel finding that sarcopenia is independently associated with reduced VO2 peak performance in CPET supports the supposition that reduced muscle mass relates to poor physical function in CRC patients. Further work should be undertaken to assess whether sarcopenia diagnosed on CT can act as suitable surrogate for CPET to further enhance personalized risk stratification.

Addressing the challenges restoring clinical services during the COVID-19 pandemic by harnessing the alignment of clinical and management leadership: an example from a large colorectal service.

BACKGROUND: The COVID-19 pandemic has posed the greatest operational challenge to the English National Health Service since its inception. Elective surgical services have struggled due to the need to protect both staff and patients from viral exposure, and perioperative COVID-19 infection has been associated with significant excess mortality. INTERVENTIONS: In this brief report, we describe how through necessity, it has provided an opportunity to redesign services for the benefit of both patients and organisations, with attendant improvement in activity compared with prepandemic metrics. We present the experience of a large district general hospital, using the department of colorectal surgery as a case study, in responding to the pandemic by restoring services and achieving improved short-term outcomes and processes in newly redesignated facilities. CONCLUSIONS: These reorganised surgical services represent a 'silver lining' of the pandemic. Clinician-led service restructuring, with positive engagement with staff at all levels, has not only addressed backlogs of urgent elective patients in a safe environment, but has also led to patient benefits and high levels of patient and staff satisfaction.

The current status of robotic colorectal surgery training programmes.

Robotic-assisted colorectal surgery (RACS) is steadily increasing in popularity with an annual growth in the number of colorectal procedures undertaken robotically. Further upscaling of RACS requires structured and standardised robotic training to safeguard high-quality clinical outcomes. The aims of this systematic review were to assess the structure and assessment metrics of currently established RACS training programmes. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines was performed. Searches were performed of the Ovid Medline, Embase and Web of Science databases between 2000 and 27th November 2021 to identify studies reporting on training curricula in RACS. Core components of training programmes and their relevant outcome assessment metrics were extracted. Thirteen studies were identified, with all training programmes designed for the da Vinci platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Common elements of multimodal programmes included theoretical knowledge (76.9%), case observation (53.8%), simulation (100%) and proctored training (76.9%). Robotic skills acquisition was assessed primarily during the simulation phase (n = 4, 30.1%) and proctoring phase (n = 10, 76.9%). Performance metrics, consisting of time or assessment scores for VR simulation were only mandated in four (30.1%) studies. Objective assessment following proctored training was variably reported and employed a range of assessment metrics, including direct feedback (n = 3, 23.1%) or video feedback (n = 8, 61.5%). Five (38.4%) training programmes used the Global Assessment Score (GAS) forms. There is a broad consensus on the core multimodal components across current RACS training programmes; however, validated objective assessment is limited and needs to be appropriately standardised to ensure reproducible progression criteria and competency-based metrics are produced to robustly assess progression and competence.

Experiences of a "COVID protected" robotic surgical centre for colorectal and urological cancer in the COVID-19 pandemic.

The recent COVID-19 pandemic led to the cancellation of elective surgery across the United Kingdom. Re-establishing elective surgery in a manner that ensures patient and staff safety has been a priority. We report our experience and patient outcomes from setting up a "COVID protected" robotic unit for colorectal and renal surgery that housed both the da Vinci Si (Intuitive, Sunnyvale, CA, USA) and the Versius (CMR Surgical, Cambridge, UK) robotic systems. "COVID protected" robotic surgery was undertaken in a day-surgical unit attached to the main hospital. A standard operating procedure was developed in collaboration with the trust COVID-19 leadership team and adapted to national recommendations. 60 patients underwent elective robotic surgery in the initial 10-weeks of the study. This included 10 colorectal procedures and 50 urology procedures. Median length of stay was 4 days for rectal cancer procedures, 2 days less than prior to the COVID period, and 1 day for renal procedures. There were no instances of in-patient coronavirus transmission. Six rectal cancer patients waited more than 62 days for their surgery because of the initial COVID peak but none had an increase T-stage between pre-operative staging and post-operative histology. Robotic surgery can be undertaken in "COVID protected" units within acute hospitals in a safe way that mitigates the increased risk of undergoing major surgery in the current pandemic. Some benefits were seen such as reduced length of stay for colorectal patients that may be associated with having a dedicated unit for elective robotic surgical services.

A novel digital rectoscope for the triage of lower gastrointestinal symptoms in primary care: a prospective multicentre feasibility study.

BACKGROUND: Access to community rectoscopy might help to ease the burden on hospital services and reduce costs for the NHS. To assess this, a prospective multicentre observational phase I feasibility study of a novel digital rectoscope and telestration software for the triage of lower gastrointestinal (GI) symptoms was undertaken. AIM: To determine if digital rectoscopy is feasible, acceptable, and clinically safe. DESIGN & SETTING: Evaluation of clinician case reports and patient questionnaires from patients recruited from five primary care centres. METHOD: Adults meeting 2-week wait (2WW) criteria for suspected lower GI cancer, suspected new diagnosis, or flare-up of inflammatory bowel disease (IBD) were enrolled. Examinations were performed by primary care practitioners using the LumenEye rectoscope. The CHiP platform allowed immediate remote review by secondary care. A prospective analysis was performed of patient and clinician experiences, diagnostic accuracy, and cost. RESULTS: A total of 114 patients were recruited and 110 underwent the procedure (46 [42%] females and 64 [58%] males). No serious adverse events were reported. Eighty-two (74.5%) patients reported that examination was more comfortable than expected, while 104 (94.5%) felt the intervention was most convenient if delivered in the community. Clinicians were confident of their assessment in 100 (87.7%) examinations. Forty-eight (42.1%) patients subsequently underwent colonoscopy, flexible sigmoidoscopy, or computed tomography virtual colonoscopy (CTVC). The overall sensitivity and specificity of LumenEye in identifying rectal pathology was 90.0% and 88.9%. It was 100% and 100% for cancer, and 83.3% and 97.8% for polyps. Following LumenEye examination, 19 (17.3%) patients were discharged, with projected savings of 11 305 GBP. CONCLUSION: Digital rectoscopy in primary care is safe, acceptable, and can reduce referrals. A phase III randomised controlled trial is indicated to define its utility in reducing the burden on hospital diagnostic services.

A Delphi consensus statement for digital surgery.

The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term 'digital surgery'. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and <30% unimportant. A final online meeting was held to discuss consensus statements. The definition of digital surgery as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm achieved 100% consensus agreement. We highlight key ethical issues concerning data, privacy, confidentiality and public trust, consent, law, litigation and liability, and commercial partnerships within digital surgery and identify barriers and research goals for future practice. Developers and users of digital surgery must not only have an awareness of the ethical issues surrounding digital applications in healthcare, but also the ethical considerations unique to digital surgery. Future research into these issues must involve all digital surgery stakeholders including patients.

Proctalgia fugax, an evidence-based management pathway.

PURPOSE: Proctalgia fugax (PF) is a benign anorectal condition which has been described in the literature since the nineteenth century commonly presenting to general surgeons. There is little high level evidence on the subject and its therapeutic modalities. We aimed through this systematic literature review to outline the definition and diagnostic criteria of this condition, the aetiology and differential diagnoses and describe the different treatment modalities that have been attempted and their success. METHOD: A literature search of Google Scholar and Medline using Pubmed as the search engine was used to identify all studies directly related to the definition, aetiology and treatment options for this condition (latest at 12 August 2008) was performed. RESULTS: The search produced 61 references with three others obtained from the references of these papers. The prevalence of PF in the general population ranges from 4% to 18%. The diagnosis is based on the presence of characteristic symptoms as defined by Rome III guidelines and physical examination. The mainstay of treatment is reassurance and careful counselling with evidence in the literature for warm baths, topical treatment with glyceryl trinitrate or diltiazem and salbutamol inhalation. In persistent cases, local anaesthetic blocks, clonidine or Botox injections can be considered after clarification of risk and benefit. CONCLUSION: Based on this we suggest that diagnosis should be made through exclusion of common organic causes such as haemorrhoids, anal fissure or anorectal carcinoma and on the fulfillment of Rome III criteria. The main treatment for this benign condition remains reassurance and topical treatment.

The influence of circumferential resection margins on long-term outcomes following rectal cancer surgery.

PURPOSE: Circumferential resection margin involvement after rectal cancer surgery is associated with local recurrence and decreased survival, but definitions of "safe" margins vary. This study assessed the influence of various circumferential margins on long-term outcome from rectal cancer surgery. METHODS: Data were extracted from a rectal cancer database of patients undergoing rectal resection at a tertiary referral center between 1971 and 1996. The influence of circumferential margins on five-year local recurrence and cancer-specific survival were assessed using Cox regression. RESULTS: Circumferential margin measurements were available from 435 patients (median follow-up, 70.4 months). Cancer-specific survival at five years was 80.8%, 69.2%, 59.2%, and 34.1% for tumors with a circumferential resection margin of >10 mm, 3-10 mm, 2 mm, and < or =1mm, respectively (P < 0.001). Local recurrence at five years was 9.0%, 14.7%, and 25.8% for margins >10 mm, 2-10 mm, and < or =1 mm, respectively (P = 0.001). Independent predictors of cancer-specific mortality were circumferential margins of < or =1 mm vs. >10 mm (odds ratio = 3.38, P = 0.014) or 2 mm (odds ratio = 2.24, P = 0.029), Dukes Stage (C2 vs. A: odds ratio = 15.18, P < 0.001), and vascular invasion (present vs. absent: odds ratio = 1.51, P = 0.033). Local recurrence was predicted by a margin of < or =1 mm (odds ratio = 2.29, P = 0.041), gender (female vs. male: odds ratio = 0.25, P = 0.002), Dukes Stage (C2 vs. A: odds ratio = 28.89, P = 0.003), and vascular invasion (extramural vs. none: odds ratio = 2.04, P = 0.024). CONCLUSION: Circumferential margins < or =2 mm are associated with significantly reduced cancer-specific survival, and margins < or =1 mm with increased local recurrence, when other factors are accounted for, challenging the assumption that a circumferential resection margin of < or =1 mm is safe.

The National Bowel Cancer Project: social deprivation is an independent predictor of nonrestorative rectal cancer surgery.

PURPOSE: This study was designed to assess the impact of social deprivation on rates of abdominoperineal excision of the rectum in the United Kingdom. METHODS: Data were extracted from the Association of Coloproctology of Great Britain and Ireland Colorectal Cancer Database (2000-2005). Social deprivation was assessed by using the Index of Multiple Deprivation (2004) score. Logistic regression was performed to identify independent predictors of nonrestorative surgery. RESULTS: A total of 12,128 patients underwent anterior resection or abdominoperineal excision for Dukes A-C cancer in 101 centers; 2,625 patients (21.6 percent) underwent abdominoperineal excision (median, 20.8 (interquartile range, 16.5-27.9) percent per unit). Abdominoperineal excision rates decreased from 24.3 to 18.2 percent (P < 0.001) and varied between the least and most deprived groups from 18 to 26.4 percent, respectively (P < 0.001). Independent predictors of abdominoperineal excision were: year of surgery (odds ratio = 0.855 per year increase, P < 0.001), female vs. male gender (odds ratio = 0.82, P < 0.001), use of neoadjuvant radiotherapy (odds ratio = 2.4, P < 0.001), and social deprivation (most vs. least deprived: odds ratio = 1.638, P < 0.001). CONCLUSIONS: Abdominoperineal excision rates vary considerably between centers. Gender and deprivation status independently predict formation of a permanent stoma. These results have important implications for intercenter comparisons of surgical quality and may suggest inequalities in health care provision.

The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases.

BACKGROUND AND AIMS: Loop ileostomies are used currently in surgical practice to reduce the consequences of distal anastomotic failure following colorectal resection. It is often assumed that reversal of a loop ileostomy is a simple and safe procedure. However, many studies have demonstrated high morbidity rates following loop ileostomy closure. The aims of this systematic review were to examine all the existing evidence in the literature on morbidity and mortality following closure of loop ileostomy. METHOD: A literature search of Ovid, Embase, the Cochrane database, Google Scholar and Medline using Pubmed as the search engine was used to identify studies reporting on the morbidity of loop ileostomy closure (latest at June 15th 2008), was performed. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital-related outcomes, post-operative bowel-related complications, and other surgical and medical complications. RESULTS: Forty-eight studies from 18 countries satisfied the inclusion criteria. Outcomes of a total of 6,107 patients were analysed. Overall morbidity following closure of loop ileostomy was found to be 17.3% with a mortality rate of 0.4%. 3.7% of patients required a laparotomy at the time of ileostomy closure. The most common post-operative complications included small bowel obstruction (7.2%) and wound sepsis (5.0%). CONCLUSION: The consequences of anastomotic leakage following colorectal resection are severe. However, the consequences of stoma reversal are often underestimated. Surgeons should adopt a selective strategy regarding the use of defunctioning ileostomy, and counsel patients further prior to the original surgery. In this way, patients at low risk may be spared the morbidity of stoma reversal.

The United Kingdom National Bowel Cancer Project -- epidemiology and surgical risk in the elderly.

OBJECTIVE: To evaluate the epidemiology and risk of surgery in the treatment of colorectal cancer in the elderly. METHODS: Patients undergoing colorectal cancer surgery were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising 47,455 patients treated over a 5-year period. Demographic characteristics and outcomes were compared between patients aged <75 and those 75 or above. The primary endpoint was 30-day mortality. Secondary endpoints were the length of hospital stay, abdominoperineal excision (APER) rates and lymph node harvest. RESULTS: Elderly patients were likely to be female and have higher American Society of Anaesthesiology (ASA) grade, while Dukes' stage was lower. They underwent surgery less often (81% versus 88%, p<0.001), but more frequently needed urgent or emergency procedures (p<0.001) and non-excisional surgery (7.7% versus 6.6%, p<0.001). Operative mortality was significantly higher for the older age group (10.6% versus 3.8%, p<0.001), and their median length-of-stay was 2 days longer (p<0.001). Mortality has improved over time for elderly patients with ASA grade III, and Dukes' stage A and D disease, but not for other subgroups. CONCLUSION: Significant differences in the demographic characteristics and operative risk-factors between under-75s, and those aged 75 or above exist. These variations are reflected in the inferior outcomes experienced by elderly patients.