Factors affecting quality of life in rectal cancer survivors who have undergone laparoscopic surgery: patient-reported outcomes over 10 years at a single institution.

INTRODUCTION: Colorectal cancer survivors have many problems affecting their quality of life (QOL). Traditional follow-up focuses on the detection of recurrence rather than QOL. Efforts are being made to assess patient-reported outcomes (PROMS) more formally. Such changes may enable patients to consider QOL factors when deciding on treatment. METHODS: Patients who underwent laparoscopic surgery for rectal cancer between 2005 and 2015 at a single institution were identified and sent European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR29 QOL questionnaires. QOL and the impact of radiotherapy, chemotherapy and formation of end colostomy were assessed. RESULTS: Some 141 patients were identified: 12 died and 118 (83.7%) responded, of whom 101 completed the questionnaires and 17 declined to participate; 11 were lost to follow-up. Mean age was 67 years, median follow-up was 58 months. Median QOL score was 6 (maximum 7) and 4.5% of patients reported a poor QOL score (<4). Significant rectal/perianal pain, sexual dysfunction and urinary symptoms were reported in 3.6%, 10.9% and 2.7% of respondents, respectively. Significant differences between treatment groups were uncommon. All cohorts reported similar QOL, functional and symptom scores. CONCLUSIONS: These results compare favourably with the published data. Future studies may benefit from baseline assessment to better assess treatment impact, prescient in an increasingly elderly and comorbid population. This paper establishes that good PROMs are achievable with laparoscopic surgery for rectal cancer. It identifies limited differences in QOL between treatment modalities. Restoration of intestinal continuity and end colostomy result in similar QOL. This may address common concerns regarding stomata, sexual function and low anterior resection syndrome in this cohort.

The increasing burden of the 2-week wait colorectal cancer pathway in a single centre: the impact of faecal immunochemical tests.

INTRODUCTION: Two-week wait (TWW) volume and colorectal cancer (CRC) detection pose an increasing challenge for NHS cancer services. Primary aims were to assess the introduction of faecal immunochemical tests (FIT) into clinical practice at our centre, the impact on TWW referral volume and CRC diagnoses, and to provide an update to previously published work. A secondary aim was to correlate FIT value and investigation. METHODS: TWW CRC data following incorporation of FIT into clinical practice were analysed (1 June 2019-31 July 2021). Parameters assessed were monthly referral volume, CRC detection, primary care FIT volume and secondary care investigations. Referrals and CRC detection rates were compared with previously published data (2009-2019). Data relating to primary care FIT were collated from Berkshire and Surrey Pathology Services. RESULTS: TWW referrals increased 360% (2009-2020). CRC incidence decreased from 8.87% to 3.24%. Following incorporation into clinical practice, primary care FIT requests have increased to >450/month and accompanied 1,722/4,796 referrals. CRC incidence is static (3-4%). Patients with FIT <10µg Hb/g faeces undergo radiological imaging more commonly, whereas FIT-positive patients are more likely to undergo endoscopy, although the difference is not statistically significant. CONCLUSIONS: No significant change in CRC diagnosis was observed, despite increasing TWW referrals. Increasing utilisation of FIT in both primary and secondary care has helped maintain CRC detection while avoiding diagnostic delay. This study supports growing evidence highlighting the value of FIT in triage, referral and TWW investigation. FIT appears increasingly important for allocating secondary care resources (endoscopy), while guiding primary care referral. Additional low-cost strategies to determine prioritisation or reassurance (e.g. repeat FIT) require further evaluation.

Patient-reported outcome measures show FIT as an acceptable investigation to rule out colorectal cancer in the two-week wait cohort.

INTRODUCTION: Use of faecal immunochemical testing (FIT) for symptomatic patients is increasing. FIT is recommended as a triage tool from primary care to the two-week wait (TWW) suspected cancer pathway, but there is still little known about patient attitudes. AIM: The aim of this study was to explore patient opinions of FIT and how it might be applied in the TWW pathway. METHODS: A telephone survey was conducted for patients from the TWW pathway who had undergone both conventional colonic investigation and FIT. Five questions explored expectations, attitudes towards results and experience of the investigations using a Likert scale 1-5. Differences in opinion were compared using median and mode scores and visualised using bar charts. RESULTS: One hundred and nine TWW patients agreed to answer the five questions. All had taken a stool sample for FIT, 50 underwent colonoscopy, 51 had a CT colonography and 8 underwent flexible sigmoidoscopy. Most patients (85%) scored 5 (completely satisfied) with these conventional colonic investigation methods they underwent for ruling out colorectal cancer (median 5). However, 30% of patients scored 5 (completely satisfied) if using a negative FIT to not require additional colonic investigation. The median score to perform FIT was 5 (very easy) compared with a median of 4 (easy) to undergo the other colonic investigations. CONCLUSIONS: Symptomatic patients can perform FIT with little difficulty, and often would have been happy to avoid conventional colonic investigations with a negative result. However, shared decision-making should be employed to identify those who would be dissatisfied with relying on FIT for further investigation decisions.

The two-week rule colorectal cancer pathway: an update on recent practice, the unsustainable burden on diagnostics and the role of faecal immunochemical testing.

INTRODUCTION: Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services. METHODS: A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports. FINDINGS: There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.

2D versus 3D laparoscopic total mesorectal excision: a developmental multicentre randomised controlled trial.

AIMS: The role of laparoscopy in rectal cancer has been questioned. 3D laparoscopic systems are suggested to aid optimal surgical performance but have not been evaluated in advanced procedures. We hypothesised that stereoscopic imaging could improve the performance of laparoscopic total mesorectal excision (TME). METHODS: A multicentre developmental randomised controlled trial comparing 2D and 3D laparoscopic TME was performed (ISRCTN59485808). Trial surgeons were colorectal consultants that had completed their TME proficiency curve and underwent stereoscopic visual testing. Patients requiring elective laparoscopic TME with curative intent were centrally randomised (1:1) to 2D or 3D using Karl Storz IMAGE1 S D3-Link™ and 10-mm TIPCAM®1S 3D passive polarising laparoscopic systems. Outcomes were enacted adverse events as assessed by the observational clinical human reliability analysis technique, intraoperative data, 30-day patient outcomes, histopathological specimen assessment and surgeon cognitive load. RESULTS: 88 patients were included. There were no differences in patient or tumour demographics, surgeon stereopsis, case difficulty, cognitive load, operative time, blood loss or conversion between the trial arms. 1377 intraoperative adverse events were identified (median 18 per case, IQR 14-21, range 2-49) with no differences seen between the 2D and 3D arms (18 (95% CI 17-21) vs. 17 (95% CI 16-19), p = 0.437). 3D laparoscopy had non-significantly higher mesorectal fascial plane resections (94 vs. 77%, p = 0.059; OR 0.23 (95% CI 0.05-1.16)) but equal lymph node yield and circumferential margin distance and involvement. 30-day morbidity, anastomotic leak, re-operation, length of stay and readmission rates were equal between the 2D and 3D arms. CONCLUSION: Feasibility of performing multicentre 3D laparoscopic multicentre trials of specialist performed complex procedures is shown. 3D imaging did not alter the number of intraoperative adverse events; however, a potential improvement in mesorectal specimen quality was observed and should form the focus of future 3D laparoscopic TME trials.

Effect of passive polarizing three-dimensional displays on surgical performance for experienced laparoscopic surgeons.

BACKGROUND: Although the potential benefits of stereoscopic laparoscopy have been recognized for years, the technology has not been adopted because of poor operator tolerance. Passive polarizing projection systems, which have revolutionized three-dimensional (3D) cinema, are now being trialled in surgery. This study was designed to see whether this technology resulted in significant performance benefits for skilled laparoscopists. METHODS: Four validated laparoscopic skills tasks, each with ten repetitions, were performed by 20 experienced laparoscopic surgeons, in both two-dimensional (2D) and 3D conditions. The primary outcome measure was the performance error rate; secondary outcome measures were time for task completion, 3D motion tracking (path length, motion smoothness and grasping frequency) and workload dimension ratings of the National Aeronautics and Space Administration (NASA) Task Load Index. RESULTS: Surgeons demonstrated a 62 per cent reduction in the median number of errors and a 35 per cent reduction in median performance time when using the passive polarizing 3D display compared with the 2D display. There was a significant 15 per cent reduction in median instrument path length, an enhancement of median motion smoothness, and a 15 per cent decrease in grasper frequency with the 3D display. Participants reported significant reductions in subjective workload dimension ratings of the NASA Task Load Index following use of the 3D displays. CONCLUSION: Passive polarizing 3D displays improved both the performance of experienced surgeons in a simulated setting and surgeon perception of the operative field. Although it has been argued that the experience of skilled laparoscopic surgeons compensates fully for the loss of stereopsis, this study indicates that this is not the case. Surgical relevance The potential benefits of stereoscopic laparoscopy have been known for years, but the technology has not been adopted because of poor operator tolerance. The first laparoscopic operation was carried out using a prototype passive polarizing laparoscopic system in 2010. This is new three-dimensional (3D) technology offers a real option for 3D laparoscopic surgery where previous systems have failed. This study is the first to have been carried out using this technology. It is essential that new technologies are adopted only when there is robust evidence to support their use. Currently, there are concerns about the use of robotic technologies and whether advantages exist for patient care. If there are advantages, 3D must be playing a significant role. If so, perhaps the technology under investigation here offers potential to a greater spectrum of surgeons, as well as being a more affordable option.

Time to adjuvant chemotherapy following colorectal cancer resection is associated with an improved survival.

AIM: Multicentre randomized trials have demonstrated equivalent long-term outcomes for open and laparoscopic resection of colon cancer. Some studies have indicated a possible survival advantage in certain patients undergoing laparoscopic resection. Patients who receive adjuvant chemotherapy in < 8 weeks following surgery can have an improved survival. METHOD: Data were collated for patients having an elective laparoscopic or open resection for non-metastatic colorectal cancer between October 2003 and December 2010 and subsequently having adjuvant chemotherapy. Survival analysis was conducted. RESULTS: In all, 209 patients received adjuvant chemotherapy following open (n = 76) or laparoscopic (n = 133) surgery. Median length of stay was 3 days with laparoscopic resection and 6 days with open resection (P < 0.0005). Median number of days to initiation of adjuvant chemotherapy was 52 with laparoscopic resection and 58 with open resection (P = 0.008). The 5-year overall survival was 89.6% in patients receiving chemotherapy in < 8 weeks after surgery, compared with 73.5% who started the treatment over 8 weeks (P = 0.016). The 5-year overall survival for those patients with a laparoscopic resection was 82.3% compared with 80.3% with an open resection (P = 0.049). CONCLUSION: There is an overall survival advantage when patients receive adjuvant chemotherapy < 8 weeks after surgery. Laparoscopic resection allows earlier discharge and, subsequently, earlier initiation of adjuvant chemotherapy.

Retrospective analysis of the effect of postoperative analgesia on survival in patients after laparoscopic resection of colorectal cancer.

BACKGROUND: Surgical excision of colorectal cancer can reduce immune function during the postoperative period, which may affect long-term survival. There is evidence that regional analgesia may attenuate the immunosuppressive effect of surgery. Opioid analgesia also suppresses cell-mediated immunity, notably natural killer cell activity. Therefore, using either epidural or spinal analgesia rather than systemic opioids during the postoperative period could affect long-term survival and disease recurrence. METHODS: A retrospective analysis of a prospective database of all patients undergoing laparoscopic colorectal resection for adenocarcinoma between October 2003 and December 2010 was performed. Patients received either an epidural, spinal block, or a morphine patient-controlled analgesia (PCA) for their primary postoperative analgesia. Overall survival and disease-free survival were analysed. RESULTS: A total of 457 laparoscopic colorectal resections were performed during the period analysed; 424 cases were suitable for analysis (epidural=107, spinal=144, and PCA=173). There was no significant difference between the groups for age, gender, conversion rate, operation performed, TNM stage, tumour differentiation, extramural venous, or lymphovascular invasion. The epidural group had significantly more ASA category III patients (P=0.006). The median length of stay was significantly longer in the epidural group at 5 days compared with 3 days for spinal and PCA (P<0.0005). There was no significant difference in overall survival (P=0.622) or disease-free survival (P=0.490) at 5 yr between the groups. CONCLUSIONS: In this study, there appears to be no significant advantage to be gained in overall or disease-free survival with the use of regional analgesia compared with opioid analgesia after laparoscopic colorectal resection.

Advanced stereoscopic projection technology significantly improves novice performance of minimally invasive surgical skills.

BACKGROUND: Three-dimensional (3D) surgical imaging systems provide stereoscopic depth cues that are lost in conventional two-dimensional (2D) display systems. Recent improvements in stereoscopic projection technology using passive polarising displays may improve performance of minimally invasive surgical skills. This study aims to identify the effect of passive polarising stereoscopic displays on novice surgeon performance of minimally invasive surgical skills. METHODS: 20 novice surgeons performed 10 repetitions of 4 surgical skills tasks using a new passive polarising stereoscopic display under 3D and 2D conditions. The previously validated tasks used were rope pass, paper cut, needle capping and knot tying. Outcome measures included total error rate and time for task completion. RESULTS: Novice surgeons demonstrated a significant reduction in error rates for sequential repetitions of each task using the passive polarising stereoscopic display compared with the 2D display. Mean errors for the 3D versus the 2D mode were 2.0 versus 4.3 for rope pass (P ≤ 0.001), 0.8 versus 1.6 for paper cut (P = 0.001), 1.3 versus 4.2 for needle capping (P ≤ 0.001) and 2.8 versus 8.0 for knot tying (P ≤ 0.001). Novice surgeons demonstrated a significant improvement in mean time for completion for all four tasks when using the 3D system. Mean time (in seconds) for 3D versus 2D were 106.5 versus 134.4 for rope pass (P ≤ 0.001), 116.1 versus 176.3 for paper cut (P ≤ 0.001), 76.3 versus 141.6 for needle capping (P ≤ 0.001) and 153.4 versus 252.6 for knot tying (P ≤ 0.001). CONCLUSION: Passive polarising stereoscopic displays significantly improve novice surgeon performance during acquisition of minimally invasive surgical skills.

Does the laparoscopic colorectal surgery learning curve adversely affect the results of colorectal cancer resection? A 3-year prospective study in a district general hospital.

INTRODUCTION: Laparoscopic colorectal surgery is slowly being adopted across the UK. We present a 3-year prospective study of laparoscopic colorectal cancer resections in a district general hospital. METHOD: Data relating to premorbid, operative and postoperative parameters were recorded for all patients undergoing laparoscopic, open, planned converted (laparoscopic assisted) and unplanned converted resections prospectively from April 2003 to April 2006. RESULTS: A total of 238 colorectal resections were performed, 153 of which were for cancer. Of these 44 (29%) were open, 77 (50%) were laparoscopic and 32 (21%) were converted [26 (17%) planned and six (4%) unplanned]. Blood loss was less in the laparoscopic group compared with the open group (P = 0.02) as was intra-operative fluid replacement (P = 0.01). Time to requiring oral analgesia alone was shorter (P = 0.001) and bowel function returned earlier (P = 0.001) in the laparoscopic group. This is reflected in a trend towards a shorter hospital stay for the laparoscopic group compared with the open group (P = 0.049). The operating time of the laparoscopic group was not significantly longer (P = 0.38). The complication rate was similar between groups (P = 0.31) and the mortality in the laparoscopic group was 1.3%. CONCLUSION: Changing from open to laparoscopic dissection for colorectal cancer is safe even during the initial learning curve. There are clear potential short-term benefits for patients and the technique can be introduced without penalties in terms of reduced surgical throughput.

Construction and characterization of a Coffea canephora BAC library to study the organization of sucrose biosynthesis genes.

The first bacterial artificial chromosome (BAC) library of Robusta coffee (Coffea canephora) was constructed, with the aim of developing molecular resources to study the genome structure and evolution of this perennial crop. Clone 126, which is highly productive and confers good technological and organoleptic qualities of beverage, was chosen for development of this library. The BAC library contains 55,296 clones, with an average insert size of 135 Kb per plasmid, therefore representing theoretically nine haploid genome equivalents of C. canephora. Its validation was achieved with a set of 13 genetically anchored single-copy and 4 duplicated RFLP probes and yielded on average 9 BAC clones per probe. Screening of this BAC library was also carried out with partial cDNA probes coding for enzymes of sugar metabolism like invertases and sucrose synthase, with the aim of characterizing the organization and promoter structure of this important class of genes. It was shown that genes for both cell wall and vacuolar forms of invertases were probably unique in the Robusta genome whereas sucrose synthase was encoded by at least two genes. One of them (CcSUS1) was cloned and sequenced, showing that our BAC library is a valuable tool to rapidly identify genes of agronomic interest or linked to cup quality in C. canephora.

Stereoscopic vision provides a significant advantage for precision robotic laparoscopy.

BACKGROUND: Current surgical robots provide no sense of touch and rely solely upon vision. This study evaluated the effect of new stereoscopic technology on the performance of robotic precision laparoscopy. METHODS: Eight experienced laparoscopists with no experience in robotics performed five tasks of increasing complexity using a laparoscopic robot. The tasks were as follows: rope pass, paper cut, needle capping, knot tying and needle threading. Each test was performed ten times under both stereoscopic and monoscopic conditions. Performance times and errors were recorded. RESULTS: Mean(s.e.m.) final performance times were calculated from the final five trial times for each test, and were as follows for monoscopic and stereoscopic conditions respectively: rope pass 112.8(4.2) and 97.0(3.7) s (P = 0.013), paper cut 117.1(6.0) and 98.4(9.8) s (P = 0.020), needle capping 144.5(12.7) and 99.7(6.8) s (P = 0.008), knot tying 138.7(14.3) and 70.3(6.0) s (P = 0.002), and needle threading 210.8(28.2) and 92.3(4.1) s (P = 0.002). The mean(s.e.m.) number of errors per candidate was 60.6(7.8) and 20.8(3.9) under monoscopic and stereoscopic conditions respectively (P = 0.004). CONCLUSION: Stereoscopic vision provided a significant advantage during robotic laparoscopy in situations that required a precise understanding of structural orientation.

Fatal bile pulmonary embolism after radiofrequency treatment of a hepatocellular carcinoma.

Radiofrequency is increasingly used to manage liver tumors. This report describes the case of a 74-year-old man who received two courses of percutaneous radiofrequency thermal ablation for a hepatocellular carcinoma over a 4-month period. He subsequently required computed tomography-guided drainage for an area of intrahepatic necrosis. During the procedure, hemobilia developed, followed by respiratory distress and collapse. The diagnosis of bile pulmonary embolism was established on the basis of high biliary acid concentrations in pulmonary fluid aspiration and blood plasma. Radiofrequency thermoablation provides local control of advanced liver tumors with low recurrence and morbidity. However, this interventional procedure risks damage to liver parenchyma involving vascular and biliary structures, which may lead to biliary-venous fistula and possible bile emboli.

The Guildford MATTU TEP hernia model.

BACKGROUND: The totally extraperitoneal technique (TEP) is a well-established method for repairing inguinal hernias laparoscopically. It has a low recurrence rate with minimal morbidity. Good training is necessary to decrease the length of the learning curve. Laparoscopic training courses at the Guildford Minimal Access Therapy Training Unit (MATTU) include lectures, live demonstrations, and practical training. In the absence of a commercially available TEP hernia model, the Guildford MATTU, along with Limbs and Things, has developed a realistic artificial model. OBJECTIVE: The aim was to develop a model that would familiarize course participants with the different anatomical perspective and the steps needed to complete the TEP repair, in an effort to shorten their learning curve. EVALUATION: The MATTU model has been evaluated in terms of anatomic accuracy, realism, versatility, cost effectiveness, and ease of use. CONCLUSIONS: The MATTU model accurately replicates TEP repair. It is robust, easy to use, cost effective, and easy to maintain. It will be widely available.

Initial experience with the use of N-butyl 2-cyanoacrylate glue for the fixation of polypropylene mesh in laparoscopic hernia repair.

The Minimal Access Therapy Training Unit at The Royal Surrey County Hospital Guildford (UK) reports on the initial success with the use of n-butyl 2-cyanoacrylate glue for fixing polypropylene mesh during laparoscopic hernia repair. We report our experience with seven such repairs and describe the prototype glue dispenser and mode of application used to fix the mesh. This is the first reported use of glue in laparoscopic hernia repair.