Using a modified Delphi process to explore international surgeon-reported benefits of robotic-assisted surgery to perform abdominal rectopexy.

BACKGROUND: Robotic-assisted surgery (RAS) offers improved visualisation and dexterity compared to laparoscopy. As a result, RAS is considered an attractive option for performing rectopexy, particularly in the confines of the lower pelvis. The aim of this study was to explore the benefits of RAS in rectopexy by analysing the views of a group of surgeons will have published on robotic rectopexy. METHODS: A three-round Delphi process was performed. Combined qualitative, Likert scale and binary responses were utilised in rounds one and two with binary responses seeking overall consensus in round two and three. Particular areas that were studied included: clinical aspects of patient selection, technical aspects of using RAS to perform rectopexy, ergonomic factors, training, and consideration of the 'learning-curve'. Consensus was defined as agreement > 80% among participants. Potential experienced RAS rectopexy surgeons were identified using PubMed where authors of studies reporting outcomes from RAS rectopexy were searched and invited. RESULTS: Twenty surgeons participated from the following countries: France, Germany, Ireland, Italy, Netherlands, Switzerland, UK, and USA. Participants had median operative experience of 75 (range 20-450) rectopexies (all techniques) and 11(range 0-300) robotic-rectopexies for all indications. All participants agreed that patient-reported functional outcomes and improved quality-of-life were the most important outcomes following rectopexy. Participants agreed the most significant benefits offered by RAS for rectopexy were improved precision due to better visualisation (80%), improved dexterity (90%) and improved overall accuracy e.g., for suture placement (90%). Ninety percent agreed that the superior ergonomics of RAS rectopexy improved their performance on several steps of the operation, in particular: mesh fixation (85%) and rectovaginal dissection (80%). Consensus on the learning curve for RAS abdominal rectopexy was not achieved: forty-five percent (n = 9) reported the learning curve as 11-20 cases and 55% (n = 11) as 21-30 cases. CONCLUSIONS: A panel of surgeons who had published on RAS view that it positively improves performance of rectopexy in terms of technical skills, improved dexterity and visualisation and ergonomics.

Open versus laparoscopic abdominal rectopexy: an examination of early postoperative outcomes.

BACKGROUND: Abdominal rectopexy is used to treat full thickness rectal prolapse and obstructed defecation syndrome, with good outcomes. Use of a laparoscopic approach may reduce morbidity. The current study assessed short-term operative outcomes for patients undergoing laparoscopic or open rectopexy. METHODS: Rectopexy cases were identified from theater logs in two tertiary referral centers. Patient demographics, intra-operative details and early postoperative outcomes were examined. RESULTS: There were 62 patients included over 10 years, a third of whom underwent laparoscopic rectopexy. Laparoscopy was associated with a longer operative time (195.9 versus 129.6 min, p = 0.003), but this did not affect postoperative outcomes, with no significant differences found for complication rates and length of stay between the two groups. Univariable analysis found no influence of laparoscopic approach on the likelihood of postoperative complications, and no factor achieved significance with multivariable analysis. This study included the first laparoscopic cases performed in the involved institutions, and a "learning curve" existed as seen with a decreasing operative duration per case over time (p = 0.002). CONCLUSIONS: Laparoscopic rectopexy has similar short-term outcomes to open rectopexy.

Palliative endoscopic trans-anal resection of advanced rectosigmoid carcinoma.

There is no consensus on optimal treatment of patients with rectosigmoid cancer and unresectable metastatic disease. This is a retrospective review of all patients who underwent palliative endoscopic trans-anal resection (ETAR) of rectosigmoid cancer over a 10-year period. Fourteen patients (11 male) with a mean age 69.7 years (range 51-86) underwent ETAR; 11 for rectal tumours and 3 for rectosigmoid tumours. Indications included tenesmus (5), troublesome bleeding (6), mucous discharge (1) and obstructed defaecation (8). The number of treatment episodes varied from 1 to 4 (median 1). The symptom-free interval was mean 6.25 months (range 2-15). Eight patients had lifelong relief of symptoms and four patients are currently symptom free. There were two short-term failures treated with stenting (1) and abdominoperineal resection (1). There were no immediate post-treatment complications. One patient developed increasing incontinence and another pelvic pain after ETAR attributable to local tumour infiltration. ETAR provides a convenient and safe method of palliation for patients with local symptoms of advanced rectosigmoid carcinoma.

Sacral nerve stimulation for faecal incontinence.

BACKGROUND: Faecal incontinence resulting from obstetric injury is a socially disabling condition with a significant impact on quality of life. Sacral nerve stimulation (SNS) is a relatively new treatment modality, which offers patients a potential for improved continence. METHODS: We reviewed our initial experience of SNS in 14 patients (mean age 54 years, range 30-72) with faecal incontinence from January 2006 to June 2007. Background demographics, past medical and obstetric history, anal manometry, endoanal ultrasound and pudendal nerve studies were recorded on all patients. All patients who had permanent SNS implants inserted had pre and post operative questionnaires consisting of the Wexner Continence Score and the Rockwood and SF-36 Quality of Life Indices. RESULTS: Out of 14 patients, 13 had incontinence related to obstetric injuries while one was related to a cauda equina syndrome. All patients had a test procedure consisting of placement of temporary electrodes and a 2-week trial of external SNS. Ten patients noted a significant improvement in their continence and these 10 patients subsequently had a permanent SNS device implanted with an overall significant improvement in continence (P < 0.001) and quality of life (P < 0.01). There were no immediate postoperative complications and one late failure consisting of a lead fracture, which was replaced successfully. Four (29%) patients did not have a significant benefit from temporary SNS and two of these patients subsequently had a colostomy. CONCLUSIONS: SNS offers improvement in continence and quality of life in patients with faecal incontinence whose only other option might otherwise be a permanent colostomy.

Ileal pouch-anal anastomosis.

BACKGROUND: Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application. METHODS AND RESULTS: Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search. CONCLUSION: The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

Routine mobilization of the splenic flexure is not necessary during anterior resection for rectal cancer.

PURPOSE: Splenic flexure mobilization is widely considered to be an essential component of anterior resection for rectal cancer. It was our hypothesis that selective splenic flexure mobilization would reduce operative times without increasing morbidity or affecting cure. METHODS: A total of 100 consecutive patients with rectal cancer (mean 8 (range, 4-15) cm from anal verge) who underwent anterior resection for cure between 1996 and 2002 had splenic flexure mobilization only as required to achieve a tension-free anastomosis. Operative time, postoperative morbidity, pathologic findings, and recurrence rates were recorded. RESULTS: There were no clinicopathologic differences between those who had splenic flexure mobilization (n = 26) and those who did not (n = 74). Mean operative time in the splenic flexure mobilization group was longer, 167 (range, 130-200) minutes vs. 120 (range, 95-180) minutes in the nonmobilized group (P = 0.023). Mean length of specimen resected was longer in the splenic flexure mobilization group: 36 vs. 18 cm (P = 0.008). Anastomotic complications (4 percent), local recurrence (7 percent, median follow-up, 38 months), perioperative morbidity (32 percent) and mortality (2 percent), and survival did not differ between the two groups. CONCLUSIONS: Routine splenic flexure mobilization is not required for safe anterior resection in patients with rectal cancer. Avoiding splenic flexure mobilization results in shorter operative times and does not increase postoperative morbidity, anastomotic leakage, or local recurrence.

Popliteal-to-distal artery bypass for diabetic limb salvage.

BACKGROUND: Poor long-term survival and significant co-morbidity among diabetic patients with limb ischaemia makes the shortest, simplest revascularisation procedure desirable. AIM: Evaluate limb salvage, primary graft patency and peri-operative morbidity rates in diabetic patients undergoing popliteal-to-distal artery bypass for limb salvage. METHODS: Patients undergoing popliteal-to-distal artery bypass for critical limb ischaemia over a seven-year period were retrospectively identified. Patients operative and follow-up data were entered into a database and limb salvage and patient survival determined using Kaplan Meier survival analysis. RESULTS: During the study period 21 popliteal-to-distal artery bypasses were performed on 19 diabetic patients. Mortality rate after one year was 11%. Primary graft patency rates among surviving patients was 81%, 67% and 48% at 1, 2 and 6 years respectively. Amputation was required in three patients. CONCLUSION: Popliteal-to-distal artery bypass produces favourable results in high-risk diabetic patients with critical limb ischaemia.

Intracorporeal rectal stapling following laparoscopic total mesorectal excision: overcoming a challenge.

BACKGROUND: Division of the rectum following total mesorectal excision (TME) using intracorporeal stapling devices is technically difficult due to their width and limited roticulation. More than one cartridge is often required and resultant wedging of the stump may be associated with an appreciable leak rate. METHODS: Three-dimensional reconstruction was performed of CT and MRI images from the lower abdomen of six patients undergoing laparoscopic TME using the Amira software environment. The stapling device was virtually reconstructed by in-house developed software, superimposed over the point of division of the rectum and the site of skin entry identified. RESULTS: The 45 degrees angulation of available roticulating stapling devices precludes perpendicular division of the rectum following laparoscopic TME. The optimal angulation for transverse rectal stapling varied between 62 degrees and 68 degrees . CONCLUSION: A roticulating stapler with minimum angulation of 65 degrees would achieve transverse division of the rectum following laparoscopic TME.

Hyaluronidase assisted reduction of intestinal intussusception; a novel application.

Failed manual reduction of entero-enteric intussusception in adults leads to intestinal resection for benign disease. The case of a twenty-year old male with an eight inch jejuno-jejunal intussusception is presented. The authors resected a hamartomatous polyp from the apex of the intussusceptum and a subsequent attempt at manual reduction was unsuccessful. Hyaluronidase was injected into the neck of the intussusception and dissipation of tissue oedema facilitated reduction within two minutes. To our knowledge, this is the first reported case of this application of Hyaluronidase.