Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients.

BACKGROUND: Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER. METHODS: A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view). RESULTS: One hundred patients were identified (median age 66, IQR 59-72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3-6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%. CONCLUSIONS: This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.

Robotic colorectal surgery: previous laparoscopic colorectal experience is not essential.

A background in minimally invasive colorectal surgery (MICS) has been thought to be essential prior to robotic-assisted colorectal surgery (RACS). Our aim was to determine whether MICS is essential prior to starting RACS training based on results from our initial experience with RACS. Two surgeons from our centre received robotic training through the European Academy of Robotic Colorectal Surgery (EARCS). One surgeon had no prior formal MICS training. We reviewed the first 30 consecutive robotic colorectal procedures from a prospectively maintained database between November 2014 and January 2016 at our institution. Fourteen patients were male. Median age was 64.5 years (range 36-82) and BMI was 27.5 (range 20-32.5). Twelve procedures (40%) were performed by the non-MICS-trained surgeon: ten high anterior resections (one conversion), one low anterior resection and one abdomino-perineal resection of rectum (APER). The MICS-trained surgeon performed nine high and four low anterior resections, one APER and in addition three right hemicolectomies and one abdominal suture rectopexy. There were no intra-operative complications and two patients required re-operation. Median post-operative stay was five days (range 1-26). There were two 30-day re-admissions. All oncological resections had clear margins and median node harvest was 18 (range 9-39). Our case series demonstrates that a background in MICS is not essential prior to starting RACS training. Not having prior MICS training should not discourage surgeons from considering applying for a robotic training programme. Safe and successful robotic colorectal services can be established after completing a formal structured robotic training programme.

Day-case closure of ileostomy: feasible, safe and efficient.

AIM: Over 5000 loop ileostomy closures were performed in the UK in 2013 with a median inpatient stay of 5 days. Previously we have successfully implemented a 23-h protocol for loop ileostomy closure which was modified for same-day discharge. We present our early experience of day-case loop ileostomy closure. METHOD: A specific patient pathway for day-case discharge following loop ileostomy closure was implemented with inclusion criteria to conform with British Association of Day Surgery guidelines. Exclusion criteria included postoperative chemoradiotherapy, multiple comorbidities and social care needs. Follow-up consisted of telephone contact (24 and 72 h after discharge) and a routine outpatient appointment. Patients were provided with a 24-h contact point in case of emergency. RESULTS: Fifteen (12 male) patients were enrolled of median age 67 (39-80) years. The median operating time was 41 (23-80) min. The indication for ileostomy formation was to cover a low anterior resection for adenocarcinoma (13), reversal of Hartmann's procedure (1) and functional bowel disorder (1). The median interval from the primary procedure to day-case loop ileostomy closure was 8 (3-14) months. Every patient was discharged on the day of surgery. There were no complications related to the surgery and there was one readmission due to a urinary tract infection. The median length of follow-up was 4 (2-16) months. CONCLUSION: Our early experience shows that day-case loop ileostomy closure is feasible, safe and efficient. This protocol will become standard within our institution for suitable patients, saving on average five inpatient bed days per patient.

One-third of patients fail to return to work 1 year after surgery for colorectal cancer.

BACKGROUND: Achieving full recovery after colorectal cancer surgery means a return to normal physical and psychological health and to a normal social life. Recovery data focusses on time to discharge rather than longer term functionality including return to work (RTW). We aim to assess return to normal holistic function at 1 year after colorectal cancer surgery. METHOD: Questionnaires were created and dispatched to 204 patients who had undergone surgery with curative intent for colorectal cancer, in 2011-2012, in a single teaching hospital. RESULTS: Response rate was 75 % (153/204), 82 % (129/157) for open surgery (OS) and 51 % (24/47) for laparoscopic surgery (LS). Median age was 68 (48-91) years for OS and 65 (36-84) for LS. Eighty-four per cent of patients felt 'ready' and 95 % had adequate pain control upon discharge (no difference between groups). LS reported earlier 'return to full fitness' (1-3 months) than OS (>6 months; Mann-Whitney U, p < 0.05). Recovery from LS was 'better than expected' compared to OS 'worse than expected' (Mann-Whitney U test, p < 0.05). Forty-nine patients were employed preoperatively and 61 % (n = 30) returned to work. RTW was more frequent after LS (Chi-square test, p < 0.05). Length of time to RTW was significantly less after LS [44 (6-84) days] than OS [71 (14-252) days] (t test, p < 0.05). Levels of self-employment were equal between groups. CONCLUSIONS: One-third of patients failed to RTW at 1 year post-surgery. Patients having LS returned to full fitness faster, felt recovery was shorter and returned to work earlier than OS. We must invest more in managing expectations and provide better post-discharge support to improve RTW.

Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER).

BACKGROUND: Extra-levator abdominoperineal excision of the rectum (ELAPER) for low rectal cancer is used to avoid the adverse oncological outcomes of inadvertent perforation and a positive circumferential resection margin associated with the conventional APER technique. This wider excision creates a large defect requiring pelvic floor reconstruction, and there is still controversy regarding the best method of closure. The aim of this study is to present outcomes of biological mesh pelvic floor reconstruction following ELAPER. METHODS: Prospective data on consecutive patients having ELAPER for low rectal cancer at a single UK institution between October 2008 and March 2013 were collected. The perineum was reconstructed using a biological mesh and the short-term outcomes were evaluated, focusing particularly on perineal wound complications and perineal hernias. RESULTS: Thirty-four patients were included [median age 62 years, range 40-72 years, 27 males (79 %)]. The median operative time was 248 min (range 120-340 min). The median length of hospital stay was 9 days (range 4-20 days). There were three perineal complications (9 %) requiring surgical intervention, but no meshes were removed. There were no perineal hernias. The median length of follow-up was 21 months (range 1-54 months). The overall mortality was 9 % from distant metastases. CONCLUSIONS: Our series adds to the increasing evidence that good outcomes can be achieved for pelvic floor reconstruction with biological mesh following ELAPER without the additional use of myocutaneous flaps. The low serious complication rate, good outcomes in perineal wound healing and the absence of perineal hernias demonstrates that this is a safe and feasible procedure.

Twenty-three-hour stay loop ileostomy closures: a pilot study.

BACKGROUND: In UK in 2010-2011, 4,463 ileostomy closures were performed (35,442 bed days) with a median inpatient stay of 5 days (Hospital Episode Statistics data). This seems anomalous when there are reports of 23-h stay colectomies. We present our early experience of 23-h discharge for loop ileostomy closures. METHODS: A specific patient journey/pathway for 23-h discharge following loop ileostomy closure was implemented at a single UK institution between August 2011 and April 2012. Follow-up was by telephone contact 24-48 h postdischarge and by routine outpatient appointment, and patients were also provided with a 24-h contact point in case of emergency. RESULTS: Twenty-three patients were included (18 male patients; median age, 63 years; range, 28-78 years). Fifteen were discharged within 23 h. The remaining 8 patients were all discharged within 48 h of surgery. Four patients were readmitted with superficial wound infection (1), slight wound discharge (1), Clostridium difficile diarrhoea (1) and an anastomotic leak 8 days after surgery (1). Median length of follow-up was 3 months (range, 1-10 months). CONCLUSIONS: A specific 23-h discharge protocol for loop ileostomy closures is feasible and safe. Improved primary care and out-of-hours hospital support would have prevented both minor wound complications requiring readmission. The anastomotic leak presented at postoperative day 8 and would have occurred in the community even if a standard protocol was used. Additional patient information and support via stoma care have been introduced to build on our experience, and 23-h stay has been introduced as standard care.

Biological mesh reconstruction of perineal wounds following enhanced abdominoperineal excision of rectum (APER).

INTRODUCTION: An abdominoperineal excision of rectum (APER) may be required for rectal tumours less than 6 cm from the anal verge. Recently, the cylindrical APER has been used to prevent the "surgical waist" and so decrease margin involvement. However, removal of the levators leaves a large defect. Myocutaneous flaps [e.g. vertical rectus abdominis (VRAM)] are often used to fill the cylindrical resection defect, but have disadvantages associated with operative time, expertise and morbidity. We report our early experience of pelvic floor reconstruction with a biological mesh following cylindrical APER. METHODS: Data on consecutive patients having cylindrical APER between January 2008 and November 2010 were collected. Outcomes were compared between a VRAM reconstruction group and a mesh group. RESULTS: In 15 consecutive patients with low rectal cancer, five patients had VRAM pelvic floor reconstruction prior to ten patients having biosynthetic mesh repairs. The median operative time for the VRAM cohort was 405 min, compared with 259 min for the mesh (p = 0.0013). The median length of postoperative stay was 20 days for VRAM and 10 days for the mesh group (p = 0.067). There were four early complications for the VRAM group compared with seven for the mesh cohort (p = 0.37). The median cost per patient for the VRAM cohort was £11,075 compared to a median cost of £6,513 for the Mesh (p = 0.0097). CONCLUSION: The use of a biological mesh for pelvic floor reconstruction following cylindrical APER is feasible with morbidity comparable to VRAM reconstruction. There is significant cost-saving using a biosynthetic mesh, mainly due to reduced length of stay.

Closure of loop ileostomy: potentially a daycase procedure?

BACKGROUND: Four thousand four hundred and twenty-seven ileostomy closures were performed in the UK in 2008-2009, (35,432 bed days). None were recorded as being performed as a daycase procedure. Our aim is to evaluate the morbidity and mortality associated with this procedure and to investigate whether daycase surgery is feasible. METHOD: Patients having closure of loop ileostomy were identified retrospectively from May 2005 to July 2010. The primary surgery, method of ileostomy closure, length of hospital stay and early (≤30 days) or late (>30 days) complications were recorded. RESULTS: A total of 138 patients were evaluated. The median age was 63 (17-83) years and 64% were male patients. The primary surgery was predominantly anterior resection (74%). Median time from initial surgery to reversal was 37 (1-117) weeks. The median length of hospital stay was 4 (1-39) days. Applying a 23-h discharge protocol to our results excluded 18 patients categorised as ASA3. Ninety-six patients (80%) met the discharge criteria for a potential 23-h hospital stay. The expected readmission rate within 30 days of surgery was 12% (n = 14). 85 patients (71%) did not suffer an early complication. There were 35 early complications (30%), 10 general and 25 specific to the procedure, but serious only in 5%. There were no deaths in the eligible patients. CONCLUSION: Closure of loop ileostomy in our series is safe, with a low serious morbidity rate. It may be feasible to perform reversal of ileostomy as a daycase/23-h stay. We intend to implement a 23-h stay for reversal of ileostomy.

Radiation induced MMP expression from rectal cancer is short lived but contributes to in vitro invasion.

AIMS: Matrix metalloproteinase (MMP) activity is increased after radiation. The aims of this study were to assess the time course of this increase and its effects on malignant cell invasion. METHODS: Colorectal cancer (HCT 116, LoVo, C 170 HM 2, CaCO-2), fibroblast (46-BR.IGI, CCD-18 Co) and fibrosarcoma (HT1080) cell lines were irradiated at 4 gray (4 Gy) and matrix metalloproteinase gene and protein expression examined over a 96 h period by real time polymerase chain reaction and gelatin zymography. Invasion was assessed on Matrigel. Human rectal tumour MMP expression was compared before and after long course radiotherapy. RESULTS: Radiation increased MMP gene expression of tumour cell lines, and resulted in increased MMP protein activity in the HT1080 line. HT1080 and HCT 116 in monoculture and LoVo in co-culture were more invasive after radiation at 48 h in vitro, but long course radiotherapy did not result in a consistent increase in MMP expression from human rectal tumour biopsies. CONCLUSIONS: Radiation results in increased MMP expression for a limited time period. This results in an early increase in cell line invasion. Further clinical research is required to clarify if MMP inhibition given perioperatively following radiotherapy decreases local recurrence rates.

Should 'doughnut' histology be routinely performed following anterior resection for rectal cancer?

Stapled low anterior resection is widely employed in the treatment of rectal adenocarcinoma. The technique yields two tissue 'doughnuts' which are often submitted for histological examination. This process is labour intensive and not part of the minimum data set for colorectal cancer histopathology reports. A consecutive series of anterior resection doughnuts from 125 patients was reviewed retrospectively to assess the impact of doughnut pathology on the management of patients. Four doughnuts had a histological abnormality reported but none of these altered treatment. Routine histological examination of 'doughnuts' is not beneficial to the management of patients undergoing surgery for rectal adenocarcinoma.

Finding the best from the rest: evaluation of the quality of patient information on the Internet.

INTRODUCTION: Information is of utmost importance for patients at risk of developing cancer who require regular screening. Quality assessment is vital to ensure correct information is published on the Internet. METHOD: A postal questionnaire was sent to patients under follow-up for Barrett's oesophagus and colonic polyps. Questions related to computer/Internet access, where patients had previously sought information, whether web-sites would be of use, and what information they would like displayed. A review of on-line patient literature for Barrett's oesophagus and colorectal adenomas was performed. RESULTS: Of the 200 questionnaires sent, 161 patients responded (80.1%). The majority of patients (88%, n = 141) wanted more information on their condition, with 45% (73) having home Internet access and a further 32% (52) having web access from other sources. Only 8% (12) had used the Internet as a source of information; however, the majority of patients (57%) would access a recommended web-site. The Barrett's search resulted in 10/200 sites with full information (i.e. score > 8/10 points). For colorectal polyps there were 12/200 sites. CONCLUSIONS: Accessing quality Internet health information is very time consuming. Recommended web-sites that provide the best information would help patients avoid being overwhelmed with irrelevant and confusing literature.

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom.

BACKGROUND: The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. METHODS: A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. RESULTS: Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). CONCLUSION: Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.