Uncertainties and opportunities in delivering environmentally sustainable surgery: the surgeons' view.

Surgery is a carbon-heavy activity and creates a high volume of waste. Surgical teams around the world want to deliver more environmentally sustainable surgery but are unsure what to do and how to create change. There are many interventions available, but resources and time are limited. Capital investment into healthcare and engagement of senior management are challenging. However, frontline teams can change behaviours and drive wider change. Patients have a voice here too, as they would like to ensure their surgery does not harm their local community but are concerned about the effects on them when changes are made. Environmentally sustainable surgery is at the start of its journey. Surgeons need to rapidly upskill their generic knowledge base, identify which measures they can implement locally and take part in national research programmes. Surgical teams in the NHS have the chance to create a world-leading programme that can bring change to hospitals around the world. This article provides an overview of how surgeons see the surgical team being involved in environmentally sustainable surgery.

Resource requirements for reintroducing elective surgery during the COVID-19 pandemic: modelling study.

BACKGROUND: The COVID-19 response required the cancellation of all but the most urgent surgical procedures. The number of cancelled surgical procedures owing to Covid-19, and the reintroduction of surgical acivirt, was modelled. METHODS: This was a modelling study using Hospital Episode Statistics data (2014-2019). Surgical procedures were grouped into four urgency classes. Expected numbers of surgical procedures performed between 1 March 2020 and 28 February 2021 were modelled. Procedure deficit was estimated using conservative assumptions and the gradual reintroduction of elective surgery from the 1 June 2020. Costs were calculated using NHS reference costs and are reported as millions or billions of euros. Estimates are reported with 95 per cent confidence intervals. RESULTS: A total of 4 547 534 (95 per cent c.i. 3 318 195 to 6 250 771) patients with a pooled mean age of 53.5 years were expected to undergo surgery between 1 March 2020 and 28 February 2021. By 31 May 2020, 749 247 (513 564 to 1 077 448) surgical procedures had been cancelled. Assuming that elective surgery is reintroduced gradually, 2 328 193 (1 483 834 - 3 450 043) patients will be awaiting surgery by 28 February 2021. The cost of delayed procedures is €5.3 (3.1 to 8.0) billion. Safe delivery of surgery during the pandemic will require substantial extra resources costing €526.8 (449.3 to 633.9) million. CONCLUSION: As a consequence of the Covid-19 pandemic, provision of elective surgery will be delayed and associated with increased healthcare costs.

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis.

BACKGROUND: Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. METHODS: A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16-45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). RESULTS: Some 5345 patients across 154 UK hospitals were identified, of which two-thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut-off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut-off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). CONCLUSION: Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision-making by identifying adults in the UK at low risk of appendicitis were identified.

ANTECEDENTES: La apendicitis es la urgencia quirúrgica de cirugía general más frecuente en todo el mundo, pero su diagnóstico sigue siendo un desafío. El objetivo de este estudio fue determinar si los modelos de predicción de riesgo existentes pueden identificar de manera fiable a los pacientes del Reino Unido que se presentan en el hospital con dolor agudo en la fosa ilíaca derecha (right iliac fossa, RIF) con bajo riesgo de apendicitis. MÉTODOS: Se realizó una búsqueda sistemática para identificar todos los modelos existentes de predicción de riesgo de apendicitis. Los modelos se validaron utilizando los datos del Reino Unido de un estudio International prospectivo de cohortes que incluía pacientes consecutivos de 16 a 45 años que se presentaron en el hospital con dolor agudo en RIF entre marzo y junio de 2017. El criterio de valoración principal fue la mejor especificidad que era posible alcanzar con el modelo (proporción de pacientes que no tenían apendicitis correctamente clasificados como de bajo riesgo) manteniendo una tasa de fracaso < 5% (proporción de pacientes identificados como de bajo riesgo que realmente tuvieron apendicitis). RESULTADOS: Se identificaron 5.345 pacientes en 154 hospitales del Reino Unido, de los cuales dos tercios (67,6%, 3.613/5.345) eran mujeres. Las mujeres tenían más del doble de probabilidades de someterse a una apendicectomía con un apéndice histológicamente normal (28,2%; 272/964) en comparación con los varones (12,1%; 120/993, riesgo relativo 2,33 (i.c. del 95% 1,92-2,84), P < 0,001)). Entre los 15 modelos de predicción de riesgo validados, el sistema de puntuación de apendicitis en adultos (Adult Appendicitis Score) fue el que obtuvo la mejor predicción (punto de corte ≤ 8, especificidad 63%, tasa de fracaso 3,7%). El sistema de puntuación de la respuesta inflamatoria de apendicitis (Appendicitis Inflammatory Response Score) fue el que obtuvo la mejor predicción en los varones (punto de corte ≤ 2, especificidad 25%, tasa de fracaso 2,4%). CONCLUSIÓN: Las mujeres del Reino Unido tuvieron un riesgo desproporcionado de ingreso sin intervención quirúrgica, así como porcentajes elevados de apendicectomías blancas. Se encontraron modelos de predicción de riesgos para apoyar la toma de decisiones compartida mediante la identificación de adultos del Reino Unido con bajo riesgo de apendicitis.

Cross-sectional observational study of the availability of evidence supporting novel implantable devices used in gastrointestinal surgery.

BACKGROUND: Evidence supporting the implementation of novel surgical devices is unstandardized, despite recommendations for assessing novel innovations. This study aimed to determine the proportion of novel implantable devices used in gastrointestinal surgery that are supported by evidence from RCTs. METHODS: A list of novel implantable devices placed intra-abdominally during gastrointestinal surgery was produced. Systematic searches were performed for all devices via PubMed and clinical trial registries. The primary outcome measure was the availability of at least one published RCT for each device. Published RCTs were appraised using the Cochrane tool for assessing risk of bias. RESULTS: A total of 116 eligible devices were identified (implantable mesh 42, topical haemostatics 22, antiadhesion barriers 10, gastric bands 8, suture and staple-line reinforcement 7, artificial sphincters 5, other 22). One hundred and twenty-eight published RCTs were found for 33 of 116 devices (28·4 per cent). Most were assessed as having a high risk of bias, with only 12 of 116 devices (10·3 per cent) supported by a published RCT considered to be low risk. A further 95 ongoing and 23 unpublished RCTs were identified for 42 of 116 devices (36·2 per cent), but many (64 of 116, 55·2 per cent) had no evidence from published, ongoing or unpublished RCTs. The highest stage of innovation according to the IDEAL Framework was stage 1 for 11 devices, stage 2a for 23 devices, stage 2b for one device and stage 3 for 33 devices. The remaining 48 devices had no relevant clinical evidence. CONCLUSION: Only one in ten novel implantable devices available for use in gastrointestinal surgical practice is supported by high-quality RCT evidence.

Longitudinal analysis of reporting and quality of systematic reviews in high-impact surgical journals.

BACKGROUND: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement aims to optimize the reporting of systematic reviews. The performance of the PRISMA Statement in improving the reporting and quality of surgical systematic reviews remains unclear. METHODS: Systematic reviews published in five high-impact surgical journals between 2007 and 2015 were identified from online archives. Manuscripts blinded to journal, publication year and authorship were assessed according to 27 reporting criteria described by the PRISMA Statement and scored using a validated quality appraisal tool (AMSTAR, Assessing the Methodological Quality of Systematic Reviews). Comparisons were made between studies published before (2007-2009) and after (2011-2015) its introduction. The relationship between reporting and study quality was measured using Spearman's rank test. RESULTS: Of 281 eligible manuscripts, 80 were published before the PRISMA Statement and 201 afterwards. Most manuscripts (208) included a meta-analysis, with the remainder comprising a systematic review only. There was no meaningful change in median compliance with the PRISMA Statement (19 (i.q.r. 16-21) of 27 items before versus 19 (17-22) of 27 after introduction of PRISMA) despite achieving statistical significance (P = 0·042). Better reporting compliance was associated with higher methodological quality (rs = 0·70, P < 0·001). CONCLUSION: The PRISMA Statement has had minimal impact on the reporting of surgical systematic reviews. Better compliance was associated with higher-quality methodology.

Diagnosing acute appendicitis: surgery or imaging?

AIM: Investigation of suspected appendicitis varies widely across different countries, which creates variation in outcome for patients. Use of imaging drives much of this variation, with concerns over delay of imaging and radiation exposure of computed tomography being balanced against the risks of unnecessary surgery. METHOD: Two national, prospective snapshot audits (UK n = 3326 and Netherlands n = 1934) reported investigation, management and outcome of appendicectomy and can be compared to generate treatment recommendations. RESULTS: Preoperative imaging was conducted in 32.8% of UK patients in contrast to 99.5% of patients in the Netherlands. A large difference in the normal appendicectomy rate was observed (20.6% in the UK vs 3.2% in the Netherlands) and the connection between these two outcome differences cannot be neglected. CONCLUSION: This article discusses the role of imaging in the diagnostic work-up of patients who are suspected of acute appendicitis, comparing national snapshot studies as a model to do so.

Learning curve for the management of recurrent and locally advanced primary rectal cancer: a single team's experience.

AIM: The study aimed to define the learning curve required to gain satisfactory training to perform pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer. METHOD: Consecutive patients undergoing exenterative pelvic surgery for recurrent and locally advanced primary rectal cancer, by one surgical team, between 2006 and 2011 were studied. They were divided into quartiles (Q1-Q4) according to the date of surgery. A risk-adjusted cumulative sum (RA-CUSUM) model was used to evaluate the learning curve. The chi-squared test with gamma ordinal was used to assess the change with time in the four quartiles. RESULTS: One hundred patients (70 males; median age 61 (25-85) years; 55 primary cancers) were included in the study. Thirty patients underwent abdominosacral resection. The number of patients who underwent plastic reconstruction (n = 53) increased from 12 in Q1 to 15 in Q4 (P = 0.781). The median operation time, intra-operative blood loss and hospital stay were 8 (3-17) h, 1.5 (0.1-17) l and 15 (9-82) days respectively. There was no significant change with time. Complete resection (R0) was achieved in 78 patients. Microscopic (R1) or macroscopic (R2) residual disease was present in 15 and seven patients respectively. The number of major complications was 20, and minor 30. RA-CUSUM analysis demonstrated an improvement in any complications after 14, in major after 12 and in minor after 25 operations. CONCLUSION: Pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer is complex and requires a minimum of 14 cases for an expert colorectal surgeon to gain the desirable training and experience to improve morbidity.

EMVI-positive stage II rectal cancer has similar clinical outcomes as stage III disease following pre-operative chemoradiotherapy.

BACKGROUND: Stage II rectal cancers comprise a heterogeneous group, and there is significant variability in practise with regards to adjuvant chemotherapy; the survival benefit of chemotherapy is perceived to be <4% in these patients. However, in recent years, the emergence of additional prognostic factors such as extramural venous invasion (EMVI) suggests that there may be sub-stratification of stage II tumours and, further, we may be under-estimating the benefit adjuvant chemotherapy provides in high-risk patients. This study examined the outcomes of patients with stage II and III rectal cancer to determine whether EMVI status influences disease-free survival (DFS). PATIENTS AND METHODS: An analysis of a prospectively maintained database was conducted of patients presenting with rectal cancer between 2006 and 2012. All patients underwent curative surgery and had no evidence of metastases at presentation. Clinicopathological factors were compared between stage II and III disease. The primary end point was 3-year DFS; univariate and multivariate analysis was carried out using Cox proportional hazards regression models; hazard ratios (HR) with 95% confidence intervals (CIs) were calculated. RESULTS: Four hundred and seventy-eight patients were included: 233 stage II; 245 stage III. The prevalence of EMVI was 34.9%; 57 stage II patients (24.5%) and 110 stage III patients (44.9%). On multivariate analysis, only EMVI status was a significant factor for DFS. The adjusted HR for EMVI either alone or in combination with nodal involvement was 2.08 (95% CI 1.10-2.95) and 2.74 (95% CI 1.66-4.52), respectively. CONCLUSION: EMVI is an independently poor prognostic factor for DFS for both stage II and stage III rectal cancer. These results demonstrate that there is risk-stratification within stage II tumours which affects prognosis. When discussing the use of adjuvant chemotherapy with patients that have EMVI-positive stage II tumours, these results provide evidence for a similarly increased risk of distant failure as stage III disease without venous invasion.

Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units.

BACKGROUND: Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. METHODS: This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. RESULTS: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091). CONCLUSION: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

Systematic review and meta-analysis of trainee- versus expert surgeon-performed colorectal resection.

BACKGROUND: The aim of this meta-analysis was to compare short-term and oncological outcomes following colorectal resection performed by surgical trainees and expert surgeons. METHODS: Systematic literature searches were made to identify articles on colorectal resection for benign or malignant disease published until April 2013. The primary outcome was the rate of anastomotic leak. Secondary outcomes were intraoperative variables, postoperative adverse event rates, and early and late oncological outcomes. Odds ratios (ORs), weighted mean differences (WMDs) and hazard ratios (HRs) for outcomes were calculated using meta-analytical techniques. RESULTS: The final analysis included 19 non-randomized, observational studies of 14,344 colorectal resections, of which 8845 (61.7 per cent) were performed by experts and 5499 (38.3 per cent) by trainees. The overall rate of anastomotic leak was 2.6 per cent. Compared with experts, trainees had a lower leak rate (3.0 versus 2.0 per cent; OR 0.72, P = 0.010), but there was no difference between experts and expert-supervised trainees (3.2 versus 2.5 per cent; OR 0.77, P = 0.080). A subgroup of expert-supervised trainees had a significantly longer operating time for laparoscopic procedures (WMD 10.00 min, P < 0.001), lower 30-day mortality (OR 0.70, P = 0.001) and lower wound infection rate (OR 0.67, P = 0.040) than experts. No difference was observed in laparoscopic conversion, R0 resection or local recurrence rates. For oncological resection, there was no significant difference in cancer-specific survival between trainees and consultants (3 studies, 533 patients; hazard ratio 0.76, P = 0.130). CONCLUSION: In selected patients, it is appropriate for supervised trainees to perform colorectal resection.

The role of epithelial mesenchymal transition and resistance to neoadjuvant therapy in locally advanced rectal cancer.

AIM: Nonresponse to neoadjuvant therapy is a significant challenge for clinicians managing solid cancers. This study aimed to determine whether epithelial mesenchymal transition (EMT) was associated with nonresponse to neoadjuvant therapy in patients with locally advanced rectal cancer. METHOD: Representative tissue specimens from the tumour-invasive front of consecutive patients undergoing resection of rectal cancer from 2009 to 2011 were used. Patients with marked regression to neoadjuvant therapy were classified as responders and the remainder were classified as nonresponders. Markers of EMT included reduced immunohistochemical expression of membranous E-cadherin, increased nuclear beta-catenin expression and tumour budding. In-situ hybridization was used to assess the expression of microRNA-200c (mir200c), an upstream master-regulator of EMT. RESULTS: Of 103 patients undergoing resection of rectal cancer, 69 received neoadjuvant chemoradiotherapy; 65% of these were nonresponders. Reduced expression of mir200c was significantly associated with a higher T grade. Reduced membranous E-cadherin, increased nuclear beta-catenin and tumour budding individually predicted the presence of extramural vascular invasion. Reduced E-cadherin, nucleic beta-catenin, reduced expression of mir200c and tumour budding were all significantly associated with nonresponse to neoadjuvant therapy (all P < 0.001). Reduced E-cadherin and expression of mir200c were both associated with reduced cancer-specific survival (log-rank P-values 0.036 and 0.009, respectively). CONCLUSION: Targeted biomarkers of EMT were associated with nonresponse to neoadjuvant therapy and reduced survival in advanced rectal cancer. EMT may provide a practical clinical biomarker and a novel therapeutic target to improve the proportion of patients who respond to neoadjuvant therapy.

Does rectal cancer height influence the oncological outcome?

AIM: The influence of the height of rectal cancer from the anal verge on the oncological outcome is controversial. This study aimed to determine the influence of the height of the tumour on the survival of patients treated in a specialized rectal cancer unit. METHOD: Patients undergoing surgery for primary rectal cancer from 2006 to 2013 were identified from a prospectively maintained rectal cancer database. Those requiring total or multicompartmental pelvic exenteration were excluded. Low cancer was defined as tumour < 5 cm from the anal verge, as assessed by endoscopy and/or digital rectal examination. The primary outcome was 3-year disease-free survival (DFS). RESULTS: Of 340 patients, 203 (59.7%) had low cancer. There were 302 (89%) restorative and 38 (11%) nonrestorative procedures. The rate of positive circumferential resection margin was similar for low compared with high cancer (3.4% vs 2.9%, P = 1.0) and for restorative compared with nonrestorative procedures in low cancer only (3.0% and 5.3%, P = 0.619). Low compared with high anterior resection was associated with increased anastomotic leakage (8.5% vs 2.2%, P = 0.023). Three-year DFS was similar for low and high resection (82% vs 86%, P = 0.305) and between restorative vs nonrestorative procedures in low cancer only (88% vs 77%, P = 0.215). In an adjusted model, low height did not lead to worse survival outcome (3-year DFS hazard ratio 0.54, 95% CI 0.24-1.24, P = 0.147). CONCLUSION: With careful planning and a multidisciplinary approach, equivalent oncological outcome can be achieved for patients with rectal cancer who undergo curative surgery regardless of differences in tumour characteristics, location and operation performed.

Reinforcement of closure of stoma site using a biological mesh.

Incisional hernia at the site of stoma closure is an under-reported problem, having been recently shown to occur in up to 30 % of patients. This technical note describes a technique for the placement of intraperitoneal biological mesh to prophylactically reinforce stoma closure sites. Seven consecutive patients underwent mesh placement as part of a pilot study. Following closure of the stoma through a trephine incision, 6 anchoring sutures were placed between the peritoneum/deep fascia and the edges of the mesh circumferentially. The mesh was delivered into the peritoneal cavity and parachuted up against the abdominal wall, and the sutures tied. If closure was performed through a midline laparotomy, the anchoring sutures were placed in a similar fashion through the midline incision. The fascia above the mesh and soft tissues was then closed. The mesh was successfully placed in all 7 patients. Follow-up at 30 days showed one superficial wound infection. An ultrasound scan of this patient revealed that the mesh was still in place and that the infection did not breach the fascia. No other early adverse events occurred. Prophylactic biological mesh reinforcement of stoma closure sites is technically feasible and safe in the short term. Longer-term results from a prospective randomised trial are needed, including clinical and radiological assessment for hernia rates, to establish what if any are the realisable benefits of this technique.

Establishing the optimum lymph node yield for diagnosis of stage III rectal cancer.

BACKGROUND: The optimum lymph node yield for tumour staging following surgery for rectal cancer remains controversial. This study aimed to determine the optimum number of lymph nodes needed to accurately determine stage III rectal cancer. METHODS: Sixty-three thousand three hundred and eighty-one patients from the surveillance, epidemiology and end resulted database, who underwent surgery for rectal adenocarcinoma in 1995-2009, were included. The primary outcome was detection of stage III rectal cancer, assessed by multivariable logistic regression. RESULTS: Each additional node examined increased the chance of stage III diagnosis by 3.9% (adjusted odds ratio 1.039, p < 0.001). Optimum histopathological stage was reached following retrieval of 18 nodes in patients treated without neoadjuvant radiotherapy (n = 49,162) and 16 nodes in those treated with neoadjuvant radiotherapy (n = 14,219). For stage I and II cancer, retrieval of a minimum of 8 and 14 nodes, respectively, was associated with optimum five-year overall survival. For stage III cancer, increasing number of positive lymph nodes and increasing lymph node ratio (>0.5) were independent negative predictors of survival; total lymph node yield did not correlate with survival. CONCLUSIONS: Eighteen lymph nodes for those treated without neoadjuvant radiotherapy and 16 nodes for those treated with it were needed to prevent stage migration in rectal cancer. These findings provide further evidence of the importance of the technique of proctectomy and of careful pathologic assessment.

Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation.

BACKGROUND: This study aimed to prospectively quantify the frequency of serious bleeding during pelvic surgery for locally advanced or recurrent rectal cancer and review the surgical methods used to control this. METHODS: Consecutive cases of pelvic surgery for curative resection of locally advanced or recurrent rectal cancer were prospectively evaluated over a nine-month period. The procedures undertaken included multivisceral resections, sacrectomies or ultra-low anterior resections. Multivisceral resections were defined as pelvic exenterations, extra-levator abdominoperineal resections (ELAPER) and recurrent anterior resections. The primary endpoint was the proportion of patients sustaining major blood loss, defined as ≥1,000 ml. The secondary endpoint was the blood transfusion rate. Haemostatic adjunct use was recorded. RESULTS: Twenty-six patients underwent surgery, comprising 11 pelvic exenterations, 3 ELAPERs, 1 recurrent anterior resection, 5 abdominosacral resections and 6 ultra-low anterior resections. The median intraoperative blood loss was 1,250 ml with 53.8 % of the patients sustaining a loss ≥1,000 ml. Fifty per cent of patients required a blood transfusion within 24 h, and one or more haemostatic adjuncts were necessary in 50 % of the cases. Adjuncts used included a fibrinogen/thrombin haemostatic agent in 38.5 % of patients, temporary intraoperative pelvic packing in 11.5 % of patients and preoperative internal iliac artery embolization in 7.7 % of patients. CONCLUSIONS: This patient group is at a high risk of intraoperative haemorrhage, and such patients are high consumers of blood products. Haemostatic adjunct use is often necessary to minimize blood loss. We describe our local algorithm to assist in the assessment and intraoperative management of these challenging cases.

A systematic review and meta-analysis of laparoscopic vs open restorative proctocolectomy.

AIM: The benefits of a laparoscopic approach to restorative proctocolectomy (RPC) are controversial. The aim of this meta-analysis was to compare the outcome following laparoscopic and open RPC, with particular attention to adverse events and long-term function. METHOD: A systematic search of the MEDLINE, EMBASE and Ovid databases was performed for studies published until March 2012. The primary end-point was long-term function. Secondary end-points were intra-operative details, short-term postoperative outcome and postoperative adverse events. Weighted mean difference (WMD) and odds ratio (OR) were calculated using fixed/random effect meta-analytic techniques. RESULTS: The final analysis included 27 comparative studies of 2428 patients, of whom 1097 (45.1%) underwent laparoscopic surgery. A laparoscopic approach was associated with a significantly longer operation time (WMD 70.1 min, P < 0.001), shorter length of hospital stay (WMD -1.00 day, P < 0.001), reduced intra-operative blood loss (WMD -89.10 ml, P < 0.001) and a lower incidence of wound infection (OR 0.60, P < 0.005). No significant differences were observed in the rate of pouch failure. Although there was no significant difference in the number of daily bowel movements (OR 0.04, P = 0.950), laparoscopic surgery led to fewer nocturnal bowel movements (WMD -1.14, P < 0.001) and reduced pad usage during the day (OR 0.22, P < 0.001) and night (OR 0.33, P < 0.001). The post hoc power to detect differences in adverse event rates ranged from 5% to 42%. CONCLUSION: Laparoscopic and open approaches to RPC produced equivalent adverse event rates and long-term functional results. However, the present evidence is underpowered to detect true differences in adverse event rates.