Implementation of a robotic surgical practice in inflammatory bowel disease.

Robotics adoption has increased in colorectal surgery. While there are well-established advantages and standardised techniques for cancer patients, the use of robotic surgery in inflammatory bowel disease (IBD) has not been studied yet. To evaluate the feasibility and safety of robotic surgery for IBD patients. Prospectively data in IBD patients having robotic resection at Guy's and St Thomas' hospital. All resections performed by a single colorectal surgeon specialised in IBD, utilising DaVinci platform. July 2021 to January 2023, 59 robotic IBD cases performed, 14 ulcerative colitis (UC) and 45 Crohn's disease (CD). Average age; CD patients 35, UC 33 years. Average Body mass index (BMI); 23 for CD and 26.9 for UC patients. In total, we performed 31 ileo-caecal resections (ICR) with primary anastomosis (18 Kono-S anastomosis, 6 mechanical anastomosis and 7 ileo-colostomy), of those 4 had multivisceral resections (large bowel, bladder, ovary). Furthermore, 14 subtotal colectomy (1 emergency), 8 proctectomy, 3 panproctocolectomy and 3 ileoanal J pouch. 18 of the 45 patients (45.0%) with Crohn's disease had ongoing fistulating disease to other parts of the GI tract (small or large bowel). ICR were performed using different three ports position, depending on the anatomy established prior to surgery with magnetic resonance images (MRI). One patient had conversion to open due to anaesthetic problems and one patient required re-operation to refashion stoma. 98.0% cases completed robotically. Median Length of hospital stay (LOS) was 7 days for CD and 7 for UC cases, including LOS in patients on pre-operative parenteral nutrition. Robotic colorectal techniques can be safely used for patients with IBD, even with fistulating disease. Future research and collaborations are necessary to standardize technique within institutions.

Racial Disparities in Pelvic Floor Disorders.

OBJECTIVE: To investigate the impact of racial disparities and Socioeconomic Status (SES) on pelvic floor disorder (PFD) care. SUMMARY BACKGROUND DATA: Racial disparities in colorectal PFD remain uninvestigated, despite prior research in urogynecology. METHODS: This retrospective study was conducted at Guy's and St. Thomas' Hospital of London in 2023. Patients with colorectal PFD from 2013 to 2018 were evaluated. Patients were classified according to the Index of Multiple Deprivation (IMD) scores and divided into quintiles. The lowest quintile represents the most deprived, whereas the higher quintile represents the least deprived. Assessed variables: patient complaint, symptoms, consultant and biofeedback referrals, investigations, multidisciplinary meeting (MDM) discussions, treatment, and follow-up appointments. RESULTS: 2001 patients were considered. A total of 1126 patients were initially analyzed, and 875 patients were excluded owing to incomplete data. Eight ethnic groups were identified in this study. Constipation was the most common compliant across ethnic groups (P=0,03). Diagnostics, MDM discussions, and conservative treatment did not vary between ethnicities. White British and Asian patients were significantly more likely to be seen by a consultant (P=0.001) and undergo surgery (P=0.002). In the second part of the study, the IMD was calculated for 1992 patients who were categorized into quintiles. Diagnostic tests, discussion in MDM, Consultant review, and surgical treatments were significantly lower in the two lowest quintiles (P<0.001, P<0.001, P=0.02, and P=0.02, respectively). Conservative treatment did not vary between the IMD groups. CONCLUSIONS: Disparities in the diagnosis and treatment of colorectal PFD exist among ethnic minorities and patients of low SES. This study allows for the replication of service provision frameworks in other affected areas to minimize inequalities.

Differences in quality of life of patients undergoing total pelvic exenteration compared with standard rectal cancer surgery: a scoping review.

AIM: Rectal cancer is often treated surgically with an anterior resection (AR) or abdominoperineal excision (APE). However, for patients with locally advanced disease or local recurrence total pelvic exenteration (TPE) surgery can be performed. The magnitude of surgery varies, and little research has been done to consider how quality of life (QoL) may vary according to the extent of surgery. METHOD: A search was conducted on MEDLINE and PubMed for papers published from 2010 to 2021. Inclusion criteria consisted of observational studies comparing adult populations with rectal cancer undergoing APE, AR or TPE, reporting QoL using validated tools. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool. Outcomes of interest were global QoL, gastrointestinal (GI) symptoms (nausea and vomiting, diarrhoea, and constipation) and pain. RESULTS: Seven studies including 1402 patients were analysed. QoL following TPE generally improves over time, back to baseline or better. AR and APE groups have similar patterns of improvement between baseline and 12 months after surgery, although scores declined in some studies at 12 months. TPE scores are lower overall, and the pattern of improvement differs, with patients tending to have worse nausea and vomiting symptoms. AR and APE patients tend to experience more lower GI symptoms. CONCLUSION: It is not possible to draw firm conclusions based on the studies analysed. However, QoL returns to baseline following TPE, APE and AR. Preoperative QoL appears to be an indication of postoperative outcomes. Further observational studies are required.

Pelvic floor imaging in asymptomatic subjects.

AIM: The aim of this work was to determine the range of normal imaging features during total pelvic floor ultrasound (TPFUS) (transperineal, transvaginal, endovaginal and endoanal) and defaecation MRI (dMRI). METHOD: Twenty asymptomatic female volunteers (mean age 36.5 years) were prospectively investigated with dMRI and TPFUS. Subjects were screened with symptom questionnaires (ICIQ-B, St Mark's faecal incontinence score, obstructed defaecation syndrome score, ICIQ-V, BSAQ). dMRI and TPFUS were performed and interpreted by blinded clinicians according to previously published methods. RESULTS: The subjects comprised six parous and 14 nulliparous women, of whom three were postmenopausal. There were three with a rectocoele on both modalities and one with a rectocoele on dMRI only. There was one with intussusception on TPFUS. Two had an enterocoele on both modalities and one on TPFUS only. There were six with a cystocoele on both modalities, one on dMRI only and one on TPFUS only. On dMRI, there were 12 with functional features. Four also displayed functional features on TPFUS. Two displayed functional features on TPFUS only. CONCLUSION: This study demonstrates the presence of abnormal findings on dMRI and TPFUS without symptoms. There was a high rate of functional features on dMRI. This series is not large enough to redefine normal parameters but is helpful for appreciating the wide range of findings seen in health.

Preoperative predictors of success after transvaginal rectocoele repair.

PURPOSE: Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment. METHODS: Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up. RESULTS: 115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure. CONCLUSION: Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.

Pelvic floor investigations for anal incontinence: Are they useful to predict outcomes from conservative treatment?

AIMS: There are several options for treating anal incontinence (AI), with limited success rate in long-term follow-up. Patients' selection is important to avoid unnecessary investigations and therapies. The aim of this review is to assess the utility of pelvic floor investigations to predict success from conservative treatment in AI. METHODS: Baseline demographics, severity scores, and pelvic floor investigations of 490 patients with AI symptoms were retrospectively reviewed. Patient-reported outcomes were used to define success of conservative treatment. RESULTS: Bivariate analysis showed that gender, St Mark's incontinence score, Bowel continence and quality of life domains of International Consultation on Incontinence Modular Questionnaire-Bowel symptoms score, Bristol stool chart, anal squeeze pressure, enterocoele, leak of contrast at rest, and dyssynergia in defecography were associated with patient's outcomes from conservative treatment (p < 0.05). Multivariate analysis showed that only the Bowel continence score was an independent predictor of patient's success with treatment. CONCLUSIONS: Pelvic floor investigations are of limited value to predict success of conservative treatment and they should be reserved for patients who fail noninvasive management and might require surgical intervention.

The association between levator plate integrity and pelvic floor defaecatory dysfunction.

AIMS: Levator ani deficiency has been implicated in anterior pelvic floor pathology but its association with pelvic floor defaecatory dysfunction is less clear. The aim was to examine the relationship of levator ani deficiency with anatomical abnormalities (rectocoele, intussusception, enterocoele, perineal descent) and patient symptoms (bowel, vagina) in patients with pelvic floor defaecatory dysfunction. METHODS: The prospective observational case series of 223 women presenting to a tertiary colorectal pelvic floor unit with defaecatory dysfunction. Each underwent assessment with symptom severity and quality of life (QoL) scores, integrated total pelvic floor ultrasound (PFUS) (transvaginal, transperineal) and defaecation proctography (DP). Rectocoele, intussusception, enterocoele and perineal descent were assessed on both. Levator ani deficiency was scored using endovaginal ultrasound (score 0-18; mild [0-6], moderate [>6-12], severe [>12-18]). RESULTS: The proportion of patients with rectocoele, enterocoele, and intussusception increased with increasing levator ani damage (mild, moderate, severe). There was a weakly positive correlation between size of rectocoele and levator ani deficiency. On PFUS, there was a weakly positive correlation between severity of intussusception and enterocoele with levator ani deficiency. On DP, there was a weakly positive correlation between perineal descent and levator ani deficiency. There was no association between bowel symptom and QoL scores and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency. CONCLUSIONS: Anatomical abnormalities which are implicated in pelvic floor defaecatory dysfunction (rectocoele, intussusception, enterocoele, perineal descent) were associated with worsening levator ani deficiency. There was no association between bowel symptoms and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

Patient pathway in a tertiary referral pelvic floor unit: Telephone triage assessment clinic.

BACKGROUND: To meet the increasing demands for colorectal pelvic floor services, a dedicated telephone triage assessment clinic (TTAC) was set up to establish a more efficient pathway, and reduce waiting times and patient's visits to the hospital. The primary aim of this study was to review TTAC in patients suffering from pelvic floor dysfunction and assess its feasibility. Secondary aims include measurement of waiting times for TTAC, main presenting complaints, and main treatment outcomes, including the need for review by a consultant surgeon. METHODS: Review of data collected retrospectively in a single tertiary referral center collected from an institutional database. KEY RESULTS: Between January 2016 and October 2017, 1192 patients referred to our pelvic floor unit were suitable for TTAC. Of these, 694 patients had complete records. There were 66 without follow-up after the initial TTAC, leaving 628 patients for analysis. In all, 86% were females and 14% were males, with a mean age of 52 years (range: 18-89). The median waiting time for TTAC was 31 days (range: 0-184). The main presenting complaint during the TTAC was obstructive defecation in 69.4%, fecal incontinence in 28.5%, and rectal prolapse in 2.1%. In our study, 611 patients had conservative management (97.3%), with a median of three sessions per patient (range: 1-16), while 82 patients (13.1%) needed a surgical intervention. Only 223 patients (35.5%) were reviewed by a consultant at some stage during the study period. CONCLUSIONS AND INFERENCES: To optimize resources, an adequate triage system allowed us to streamline the pathway for each individual patient with pelvic floor dysfunction according to their symptoms and/or test results with the aim of reducing waiting times and expediting treatment.

Total pelvic floor ultrasound can reliably predict long-term treatment outcomes for patients with pelvic floor defaecatory dysfunction.

AIM: Integrated total pelvic floor ultrasound (TPFUS) may provide an alternative to defaecation proctography (DP) in decision making and treatment planning for patients with pelvic floor defaecatory dysfunction (PFDD). This study evaluates the use of TPUS as a screening tool, and its likelihood to predict long-term treatment outcomes. METHODS: Two blinded clinicians reviewed 100 women who had historically presented to a tertiary referral colorectal unit with PFDD from October 2014 to April 2015. The clinical history of the patients together with TPFUS or DP results were used to decide on main impression, treatment plan, likelihood of surgery and certainty of plan. These were compared to the actual treatment received six months later and again after a median follow-up of 68 months (range 48-84). RESULTS: A total of 82 patients were treated with biofeedback only and 18 also underwent surgery. There were no complications in any of the patients who had surgery. When compared with the actual treatment received, 99 of the 100 of the TPFUS group would have been treated appropriately. The number of false positives for surgical treatment was lower with TPFUS compared to DP. Clinician confidence in the overall decision was significantly higher after review with DP. CONCLUSIONS: TPFUS is a reliable assessment tool for PFDD. It can identify patients who can go straight to biofeedback and is just as good as DP at predicting likelihood of surgery. We might be able to rely on TPFUS more significantly in the future, even for surgical planning.

Early Barriers to Career Progression of Women in Surgery and Solutions to Improve Them: A Systematic Scoping Review.

OBJECTIVE: This study aims to summarize the evidence concerning the barriers that exist to the career progression of women in surgery and to provide potential solutions to overcome these obstacles. BACKGROUND: Visible and invisible impediments can hinder female doctors' pursuit of a surgical career, from choosing a surgical specialty to training opportunities and all the way through career progression. METHODS: Database search of original studies about barriers for female surgeons during choice of surgical career, residency, and career progression. A query including possible solutions such as mentorship and network was included. RESULTS: Of 4618 total articles; 4497 were excluded as duplicates, having incorrect study focus, or not being original studies; leaving 120 studies meeting the inclusion criteria. Of the articles included, 22 (18%) focused on factors affecting the pursuit of a surgical career, such as surgical work hours and limited time for outside interests, 55 (46%) analyzed the main barriers that exist during surgical residency and fellowship training, such as discrimination and sexual harassment, 27 (23%) focused on barriers to career advancement, heavy workloads, ineffective mentorship, unclear expectations for advancement, inequality in pay or work-home conflicts. Among studies reporting on possible solutions, 8 (6.5%) articles reported on the role of effective mentorship to support career advancement and to provide moral support and 8 (6.5%) on the emerging role of social media for networking. Our analysis showed how different impediments hinder surgical career progression for women, with notable consequences on burnout and attrition. CONCLUSIONS: Identification and recognition of obstacles to career progression is the first step to addressing the gender gap in surgery. Active strategies should be improved to promote a culture of diversity and to create equal opportunity for women in surgery, while implementing structured mentoring programs and investing on an adequate communication on social media to engage the future generations.

Women surgeons: How can we shape the future of new leaders? A celebration of the past with a glimpse of the future.

BACKGROUND: Sporadic women involvement in surgery has been recorded since ancient times. Nevertheless, the presence of women in surgical disciplines has been marginal until the last 2 decades, with several barriers still existing worldwide. The aim of the study was to explore the history of women in surgery, with a main focus in North America from until the foundation women surgical societies. METHODS: Database search of studies about the history of women in surgery. RESULTS: The 19th century registered an increased presence of women in medicine; during the 20th century, pioneer women surgeons opened the way to a more consistent involvement of women in surgical specialties. In the last 20 years, increased awareness of barriers limiting women progression in surgical career led to the development of women's surgical societies, with the aim to share common experiences and find solutions to common issues. CONCLUSION: The history of women in surgery has been paved with challenges: during the last centuries, several barriers limited the inclusion of women in surgical fields, from training to leadership positions. Nevertheless, some pioneers actually broke the rules imposed by a male-dominated field and opened the way to a more diverse and equal future for women surgeons. Nowadays, the existence of women's surgical societies in different countries and their interconnection represents a way to support women surgeons at different stages of their career.

Transvaginal rectocoele repair for the surgical treatment of a "symptomatic" rectocoele when conservative measures fail: A 12 year experience of 215 patients.

BACKGROUND: Conservative measures are first-line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery. METHODS: We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in-hospital and 30 days post-operative complications and pre- and post-operative symptoms. KEY RESULTS: The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in-hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow-up was 12.7 months (SD 13.9, range 1.4-71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS-related symptoms improved in 58% of cases. CONCLUSIONS & INFERENCES: The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms.

Discrimination Toward Women in Surgery: A Systematic Scoping Review.

BACKGROUND: Over the past twenty years explicit gender bias toward women in surgery has been replaced by more subtle barriers, which represent indirect forms of discrimination and prevents equality. OBJECTIVE: The aim of our scoping review is to summarize the different forms of discrimination toward women in surgery. METHODS: The database search consisted of original studies regarding discrimination toward female surgeons. RESULTS: Of 3615 studies meeting research criteria, 63 were included. Of these articles, 11 (18%) were focused on gender-based discrimination, 14 (22%) on discrimination in authorship, research productivity, and research funding, 21 (33%) on discrimination in academic surgery, 7 (11%) on discrimination in surgical leadership positions and 10 (16%) on discrimination during conferences and in surgical societies. The majority (n = 53, 84%) of the included studies were conducted in the U.S.A. According to our analysis, female surgeons experience discrimination from male colleagues, healthcare workers, but also from patients and trainees. Possible solutions may include acknowledgment of the problem, increased education of diversity and integration for the younger generations, mentorship, coaching, and more active engagement by male and female partners to support women in the surgical field. CONCLUSIONS: Gender-based discrimination toward women in the field of surgery has evolved over the past twenty years, from an explicit to a more subtle attitude. A work-environment where diversity and flexibility are valued would allow female surgeons to better realize their full potential.

Anal endosonographic assessment of the accuracy of clinical diagnosis of obstetric anal sphincter injury.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASIS) are a common cause of maternal morbidity with an overall incidence in the UK of 2.9% (range 0-8%). They can cause a range of physical symptoms and psychological distress. This study aims to assess the accuracy of clinical diagnosis of OASIS using endoanal ultrasound (EAUS) and the correlation between confirmed injury and change to anorectal physiology squeeze pressure and the incidence of bowel symptoms. METHODS AND MATERIALS: Retrospective study of prospectively collected data from 1135 women who attended the Third- and Fourth-Degree Tears Clinic at our institution, 12 weeks post-delivery, between June 2008 and October 2019. RESULTS: OASIS was confirmed in 876 (78.8%) women and 236 (21.3%) had no injury. Of the women who underwent anorectal physiology, 45.6% had a mean maximal resting pressure below the normal range and 68.8% had a mean incremental squeeze pressure below normal. Women with confirmed OASIS had significantly lower pressures (p < 0.001) than those without a confirmed sphincter injury. Three hundred ninety-three (34.8%) women reported bowel symptoms, with those with endosonographic evidence of injury more likely to develop flatus incontinence. CONCLUSION: Of the women in this study with a suspected OASIS, 21.2% could be reassured that they did not have an injury. This information is useful for women considering future mode of delivery. Those with confirmed injury are more likely to complain of flatus incontinence and have reduced anal sphincter pressures.

Interferon signature in immunosuppressed patients with lower respiratory tract infections: dosage on bronchoalveolar lavage.

BACKGROUND: Interferon signature (IS) is the measure of transcripts belonging to pathways of interferon activation. Viral infections can interfere with the interferon pathway, in particular herpesvirus present in immunocompromised hosts. The aim of our study was to evaluate if herpesvirus infections in immunocompromised patients with lower respiratory tract infections (LRTI) could lead to IS alterations. METHODS: We measured IS transcription of six genes on bronchoalveolar lavage of immunocompromised patients with LRTI (IFI27, IFI44, IFIT1, ISG15, RSAD2, SIGLEC1). Patients were divided in three groups based on Epstein-Barr virus (EBV) and other herpesviruses coinfections. RESULTS: We included 56 patients, 10 without and 17 with only EBV reactivation (respectively N and E groups) and 29 with EBV and other herpesviruses (group C). IS was higher in group C (P=0.01) compared to other ones, but single gene expressions were different among groups: IFI27 was higher whereas IFIT1 and ISG15 were lower in group C (P<0.05). CONCLUSIONS: The continuous stimulation of interferon cascade by herpesviruses enhances IS. The analysis of IS in immunocompromised population is possible by limiting the use of IFI27, IFIT1, ISG15 genes. Our preliminary results seem to indicate that IS is a useful biomarker of cellular response to herpesvirus infection in immunocompromised patients.