Robotic assisted surgery reduces ergonomic risk during minimally invasive colorectal resection: the VOLCANO randomised controlled trial.

PURPOSE: Minimally invasive surgery benefits patients but poor operating ergonomics causes musculoskeletal injuries in surgeons. This randomised controlled trial aims to assess whether robotic-assisted surgery with the open-console Versius® system can reduce surgeons' ergonomic risks during major colorectal resections. METHODS: Prospectively registered at ClinicalTrials.gov (NCT05262296) in March 2022. Adult patients requiring a minimally invasive colorectal resection were potentially eligible. Photographs taken at 2-min intervals were analysed using the objective Rapid Entire Body Assessment (REBA) posture analysis scale to calculate intraoperative surgeon ergonomic risk. Secondary outcomes included team communication (Oxford NOTECHS II), surgeon cognitive strain (modified NASA-TLX scale), and clinical outcomes. RESULTS: Sixty patients were randomised in a 2:1 ratio (40 robot, 20 laparoscopic). Mean age was 65yrs and 34 (57%) were male. Body Mass Index did not differ between the 2 groups (overall mean 29.0 ± 5) and there were equal proportions of left and right-colonic resections. REBA was significantly lower in the robotic arm (median robot REBA score 3 vs lap REBA 5 [p < 0.001]), equating to an injury risk category drop from "medium" to "low risk". There were no significant differences in team communication, operative duration, or patient outcomes. Surgeon cognitive strain was lower in robotic cases (mean robot 32.4 ± 10.3 vs lap 45.6 ± 14.3 [p < 0.001]). CONCLUSIONS: This trial demonstrates that robotic surgery with an open-console system reduces ergonomic risk scores and cognitive strain during colorectal resections, with no apparent detriment to team communication. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons.

The ICaRAS randomised controlled trial: Intravenous iron to treat anaemia in people with advanced cancer - feasibility of recruitment, intervention and delivery.

BACKGROUND: Anaemia is highly prevalent in people with advanced, palliative cancer yet sufficiently effective and safe treatments are lacking. Oral iron is poorly tolerated, and blood transfusion offers only transient benefits. Intravenous iron has shown promise as an effective treatment for anaemia but its use for people with advanced, palliative cancer lacks evidence. AIMS: To assess feasibility of the trial design according to screening, recruitment, and attrition rates. To evaluate the efficacy of intravenous iron to treat anaemia in people with solid tumours, receiving palliative care. DESIGN: A multicentre, randomised, double blind, placebo-controlled trial of intravenous iron (ferric derisomaltose, Monofer®). Outcomes included trial feasibility, change in blood indices, and change in quality of life via three validated questionnaires (EQ5D5L, QLQC30, and the FACIT-F) over 8 weeks. (ISRCTN; 13370767). SETTING/PARTICIPANTS: People with anaemia and advanced solid tumours who were fatigued with a performance status ⩽2 receiving support from a specialist palliative care service. RESULTS: 34 participants were randomised over 16 months (17 iron, 17 placebo). Among those eligible 47% of people agreed to participate and total study attrition was 26%. Blinding was successful in all participants. There were no serious adverse reactions. Results indicated that intravenous iron may be efficacious at improving participant haemoglobin, iron stores and select fatigue specific quality of life measures compared to placebo. CONCLUSION: The trial was feasible according to recruitment and attrition rates. Intravenous iron increased haemoglobin and may improve fatigue specific quality of life measures compared to placebo. A definitive trial is required for confirmation.

Implementation of robotic hernia surgery using the Versius® system.

This case series aims to demonstrate that hernia surgery is safe and feasible using the Versius® robotic system from CMR Surgical, and to describe the surgical techniques used. It is the first series published using this novel system. Forty-one consecutive hernia repair cases were completed using Versius®, including inguinal and ventral hernias. Data were collected prospectively on a number of pre-, peri-, and postoperative outcomes. Techniques are described for robotic transabdominal preperitoneal repair of inguinal hernia, and intraperitoneal onlay mesh repair of ventral hernia. Thirty-two inguinal and nine ventral hernia repairs were performed over a 12-month period. The population were 88% male with a mean body mass index of 27.4 ± 3.5. There were no conversions to open surgery. Median length of stay was 0 days. Six patients (15%) experienced urinary retention, and there were 2 further minor complications with no major complications, readmissions or reoperations. Use of the Versius® system for robotic hernia surgery is safe, with comparable results to existing robotic systems. Implementation is possible with minimal changes to established surgical techniques.

Initiation and feasibility of a multi-specialty minimally invasive surgical programme using a novel robotic system: A case series.

INTRODUCTION: There are a number of small case series examining new robotic surgical systems, but this is the first large case series assessing the feasibility of the Versius® system from CMR Surgical (1 Evolution Business Park, Cambridge, UK) in a multi-specialty setting. MATERIALS AND METHODS: All patients undergoing Versius®-assisted surgery in a previously robot-naïve centre were consented for collection of data on demographics, pre-, intra-, and postoperative outcomes. Data collection was performed prospectively from the start of the robotic surgical programme. RESULTS: 160 operations were performed over a 19-month period, including 68 colorectal, 60 gynaecology, and 32 general surgery cases. The conversion rate to open surgery was 4.4% for colorectal, and 0% for gynaecology and general surgery. Median length of stay was 6 days for colorectal, 1 day for gynaecology, and 0 days for general surgery. Other outcomes were comparable to existing literature for robotic assisted surgery. CONCLUSION: The Versius® system is safe and feasible for use in a multi-specialty minimally invasive surgery programme, including colorectal, general surgical & gynaecological cases, and operative volume can be safely and easily scaled up in a district general hospital setting without prior robotic surgical experience.

Open Appendicectomy under Spinal Anesthesia-A Valuable Alternative during COVID-19.

Introduction Concerns relating to coronavirus disease 2019 (COVID-19) and general anesthesia (GA) prompted our department to consider that open appendicectomy under spinal anesthesia (SA) avoids aerosolization from intubation and laparoscopy. While common in developing nations, it is unusual in the United Kingdom. We present the first United Kingdom case series and discuss its potential role during and after this pandemic. Methods We prospectively studied patients with appendicitis at a British district general hospital who were unsuitable for conservative management and consequently underwent open appendicectomy under SA. We also reviewed patient satisfaction after 30 days. This ran for 5 weeks from March 25th, 2020 until the surgical department reverted to the laparoscopic appendicectomy as the standard of care. Main outcomes were 30-day complication rates and patient satisfaction. Results None of the included seven patients were COVID positive. The majority (four-sevenths) had complicated appendicitis. There were no major adverse (Clavien-Dindo grade III to V) postoperative events. Two patients suffered minor postoperative complications. Two experienced intraoperative pain. Mean operative time was 44 minutes. Median length of stay and return to activity was 1 and 14 days, respectively. Although four stated preference in hindsight for GA, the majority (five-sevenths) were satisfied with the operative experience under SA. Discussion Although contraindications, risk of pain, and specific complications may be limiting, our series demonstrates open appendicectomy under SA to be safe and feasible in the United Kingdom. The technique could be a valuable contingency for COVID-suspected cases and patients with high-risk respiratory disease.

A colorectal straight-to-test cancer pathway with general-practitioner-guided triage improves attainment of the 28-day diagnosis target and increases outpatient clinic capacity.

AIM: This study investigates whether a straight-to-test (STT) colorectal cancer pathway improves attainment of the National Health Service (NHS) England 28-day Faster Diagnosis Standard and the effect of the pathway on reducing face-to-face outpatient clinic appointments. Patient satisfaction and the safety of a novel general practitioner (GP) led patient triage system regarding suitability for colonoscopy are also evaluated. METHODS: This is an observational study of all patients managed via an STT colorectal cancer pathway between 1 September 2019 and 19 March 2020. Comparison is made with all patients referred on the suspected colorectal cancer pathway prior to implementation of the STT pathway from 1 January 2019 to 30 July 2019. Patient satisfaction with the STT pathway was assessed with a telephone-based questionnaire. RESULTS: Attainment of the 28-day diagnosis target for all suspected colorectal cancer referrals improved following the establishment of the STT pathway (88% vs. 82%, P < 0.0001). From a potential total of 548 outpatient colorectal clinic appointments for patients on the STT pathway, 504 (92%) were avoided. In those eligible for the STT pathway, GP assessment of patients suitable for colonoscopy agreed with that of the colorectal department in 93% of cases. Of the 50 patients who undertook the satisfaction survey, 86% were satisfied or very satisfied with the pathway. No patient suffered adverse events as a result of their STT investigations. CONCLUSION: An STT pathway for suspected colorectal cancer referrals with novel GP-led patient triage safely streamlines patients through the suspected colorectal cancer diagnostic pathway and significantly reduces requirement for face-to-face outpatient clinic attendance. This is achieved with high patient satisfaction.

Iron therapy for preoperative anaemia.

BACKGROUND: Preoperative anaemia is common and occurs in 5% to 76% of patients preoperatively. It is associated with an increased risk of perioperative allogeneic blood transfusion, longer hospital stay, and increased morbidity and mortality. Iron deficiency is one of the most common causes of anaemia. Oral and intravenous iron therapy can be used to treat anaemia. Parenteral iron preparations have been shown to be more effective in conditions such as inflammatory bowel disease, chronic heart failure and postpartum haemorrhage due to rapid correction of iron stores. A limited number of studies has investigated iron therapy for the treatment of preoperative anaemia. The aim of this Cochrane Review is to summarise the evidence for iron supplementation, both enteral and parenteral, for the management of preoperative anaemia. OBJECTIVES: To evaluate the effects of preoperative iron therapy (enteral or parenteral) in reducing the need for allogeneic blood transfusions in anaemic patients undergoing surgery. SEARCH METHODS: We ran the search on 30 July 2018. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic and Embase (Ovid), CINAHL Plus (EBSCO), PubMed, and clinical trials registries, and we screened reference lists. We ran a top-up search on 28 November 2019; one study is now awaiting classification. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) that compared preoperative iron monotherapy to placebo, no treatment, standard care or another form of iron therapy for anaemic adults undergoing surgery. We defined anaemia as haemoglobin values less than 13 g/dL for males and 12 g/dL for non-pregnant females. DATA COLLECTION AND ANALYSIS: Two review authors collected data and a third review author checked all collected data. Data were collected on the proportion of patients who receive a blood transfusion, the amount of blood transfused per patient (units), quality of life, ferritin levels and haemoglobin levels, measured as continuous variables at the following predetermined time points: pretreatment (baseline), preoperatively but postintervention, and postoperatively. We performed statistical analysis using the Cochrane software, Review Manager 5. We summarised outcome data in tables and forest plots. We used the GRADE approach to describe the quality of the body of evidence. MAIN RESULTS: Six RCTs, with a total of 372 participants, evaluated preoperative iron therapy to correct anaemia before planned surgery. Four studies compared iron therapy (either oral (one study) or intravenous (three studies)) with no treatment, placebo or usual care, and two studies compared intravenous iron therapy with oral iron therapy. Iron therapy was delivered over a range of periods that varied from 48 hours to three weeks prior to surgery. The 372 participants in our analysis fall far short of the 819 required - as calculated by our information size calculation - to detect a 30% reduction in blood transfusions. Five trials, involving 310 people, reported the proportion of participants who received allogeneic blood transfusions. Meta-analysis of iron therapy versus placebo or standard care showed no difference in the proportion of participants who received a blood transfusion (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.87 to 1.70; 4 studies, 200 participants; moderate-quality evidence). Only one study that compared oral versus intravenous iron therapy measured this outcome, and reported no difference in risk of transfusion between groups. There was no difference between the iron therapy and placebo/standard care groups for haemoglobin level preoperatively at the end of the intervention (mean difference (MD) 0.63 g/dL, 95% CI -0.07 to 1.34; 2 studies, 83 participants; low-quality evidence). However, intravenous iron therapy produced an increase in preoperative postintervention haemoglobin levels compared with oral iron (MD 1.23 g/dL, 95% CI 0.80 to 1.65; 2 studies, 172 participants; low-quality evidence). Ferritin levels were increased by intravenous iron, both when compared to standard care ((MD 149.00, 95% CI 25.84 to 272.16; 1 study, 63 participants; low-quality evidence) or to oral iron (MD 395.03 ng/mL, 95% CI 227.72 to 562.35; 2 studies, 151 participants; low-quality evidence). Not all studies measured quality of life, short-term mortality or postoperative morbidity. Some measured the outcomes, but did not report the data, and the studies which did report the data were underpowered. Therefore, uncertainty remains regarding these outcomes. The inclusion of new research in the future is very likely to change these results. AUTHORS' CONCLUSIONS: The use of iron therapy for preoperative anaemia does not show a clinically significant reduction in the proportion of trial participants who received an allogeneic blood transfusion compared to no iron therapy. Results for intravenous iron are consistent with a greater increase in haemoglobin and ferritin when compared to oral iron, but do not provide reliable evidence. These conclusions are drawn from six studies, three of which included very small numbers of participants. Further, well-designed, adequately powered, RCTs are required to determine the true effectiveness of iron therapy for preoperative anaemia. Two studies are currently in progress, and will include 1500 randomised participants.

LAP-VEGaS Practice Guidelines for Reporting of Educational Videos in Laparoscopic Surgery: A Joint Trainers and Trainees Consensus Statement.

OBJECTIVE: Consensus statement by an international multispecialty trainers and trainees expert committee on guidelines for reporting of educational videos in laparoscopic surgery. SUMMARY OF BACKGROUND DATA: Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but there are no guidelines for video annotation or procedural educational and safety evaluation. METHODS: Delphi questionnaire of 45 statements prepared by a steering group and voted on over 2 rounds by committee members using an electronic survey tool. Committee selection design included representative surgical training experts worldwide across different laparoscopic specialties, including general surgery, lower and upper gastrointestinal surgery, gynecology and urology, and a proportion of aligned surgical trainees. RESULTS: All 33 committee members completed both the first and the second round of the Delphi questionnaire related to 7 major domains: Video Introduction/Authors' information; Patient Details; Procedure Description; Procedure Outcome; Associated Educational Content; Peer Review; and Use in Educational Curriculae. The 17 statements that did not reach at least 80% agreement after the first round were revised and returned into the second round. The committee consensus approved 37 statements to at least an 82% agreement. CONCLUSION: Consensus guidelines on how to report laparoscopic surgery videos for educational purposes have been developed. We anticipate that following our guidelines could help to improve video quality.These reporting guidelines may be useful as a standard for reviewing videos submitted for publication or conference presentation.

A cohort investigation of anaemia, treatment and the use of allogeneic blood transfusion in colorectal cancer surgery.

INTRODUCTION: Preoperative identification and treatment of anaemia is advocated as part of Patient Blood Management due to the association of adverse outcome with the perioperative use of blood transfusion. This study aimed to establish the rate of anaemia identification, treatment and implications of this preoperative anaemia on ARBT use. METHODS: All patients who underwent elective surgery for colorectal cancer over 18 months at a single Tertiary Centre were reviewed. Electronic databases and patient casenotes were reviewed to yield required data. RESULTS: Complete data was available on 201 patients. 67% (n = 135) had haemoglobin tested at presentation. There was an inverse correlation between tumour size and initial haemoglobin (P < 0.01, Rs = -0.3). Initial haemoglobin levels were significantly lower in patients with right colonic tumours (P < 0.01). Patients who were anaemic preoperatively received a mean 0.91 units (95%CI 0-0.7) per patient which was significantly higher than non-anaemic patients (0.3 units [95%CI 0-1.3], P < 0.01). For every 1 g/dl preoperative haemoglobin increase, the likelihood of transfusion was reduced by approximately 40% (OR 0.57 [95%CI 0.458-0.708], P < 0.01). Laparoscopic surgery was associated with fewer anaemic patients transfused (P < 0.01). CONCLUSION: Haemoglobin levels should be routinely checked at diagnosis of colorectal cancer, particularly those with large or right sided lesions. Early identification of anaemia allows initiation of treatment which may reduce transfusion risk even with modest haemoglobin rises. The correct treatment of this anaemia needs to be established.

Iron therapy for pre-operative anaemia.

BACKGROUND: Pre-operative anaemia is common and occurs in up to 76% of patients. It is associated with increased peri-operative allogeneic blood transfusions, longer hospital lengths of stay and increased morbidity and mortality. Iron deficiency is one of the most common causes of this anaemia. Oral iron therapy has traditionally been used to treat anaemia but newer, safer parenteral iron preparations have been shown to be more effective in other conditions such as inflammatory bowel disease, chronic heart failure and post-partum haemorrhage. A limited number of studies look at iron therapy for the treatment of pre-operative anaemia. The aim of this Cochrane review is to summarise the evidence for use of iron supplementation, both enteral and parenteral, for the management of pre-operative anaemia. OBJECTIVES: The objective of this review is to evaluate the effects of pre-operative iron therapy (enteral or parenteral) in reducing the need for allogeneic blood transfusions in anaemic patients undergoing surgery. SEARCH METHODS: We ran the search on 25 March 2015. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic and EMBASE (Ovid), CINAHL Plus (EBSCO), PubMed, clinical trials registries, conference abstracts, and we screened reference lists. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) which compared pre-operative iron monotherapy to placebo, no treatment, standard of care or another form of iron therapy for anaemic adults undergoing surgery. Anaemia was defined by haemoglobin values less than 13 g/dL for males and 12 g/dL for non-pregnant females. DATA COLLECTION AND ANALYSIS: Data were collected by two authors on the proportion of patients who receive a blood transfusion, amount of blood transfused per patient (units) and haemoglobin measured as continuous variables at pre-determined time-points: pre-treatment, pre-operatively but post-treatment, and post-operatively. Statistical analysis was performed using the Cochrane statistical software, Review Manager 2014. Outcome data were summarised in tables and a forest plot. MAIN RESULTS: Three prospective randomised controlled studies evaluated pre-operative iron therapy to correct anaemia (two in colorectal and one in gynaecological surgery) and included 114 patients in total. One compared oral iron versus standard care (Lidder 2007); one intravenous iron versus control (Edwards 2009); and one study compared oral versus intravenous iron (Kim 2009). Both colorectal trials reported the primary outcome (proportion of patients who received allogeneic blood transfusions) and meta-analysis showed a reduction in blood transfusions with the administration of iron therapy, but the reduction was not statistically significant (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.27 to 1.18). All studies reported haemoglobin change but data for the anaemic patients were only available for two studies (Edwards 2009 and Kim 2009). Edwards 2009 showed no difference in haemoglobin at the end of treatment pre-operatively. The intravenous versus oral iron study showed an increase in haemoglobin with intravenous iron at the end of treatment pre-operatively (MD 1.90 g/dL, 95% CI 1.16 to 2.64; participants = 56), but the results are at high risk of bias because participants with less than 80% compliance with therapy were excluded from the analysis and compliance was lower in the oral iron group due to the side-effects of treatment (Kim 2009).None of the studies reported quality of life, short- or long-term mortality or post-operative morbidity. AUTHORS' CONCLUSIONS: The use of iron therapy for pre-operative anaemia does not show a statistically significant reduction in the proportion of patients who received an allogeneic blood transfusion compared to no iron therapy. However, the 38 patients in our analysis falls far short of the 819 patients our information size calculation recommended to detect a 30% reduction in blood transfusions. Intravenous iron may be more effective than oral iron at increasing haemoglobin. However, all these conclusions are drawn from only three small randomised controlled studies. Further well designed, adequately powered randomised controlled studies are required to determine the true effectiveness of iron therapy for pre-operative anaemia.

Snapshot quiz - recurrent right iliac fossa pain in the patient with a previous history of appendicitis.

A low threshold for computed tomography (CT) scanning in patients with previous appendicectomy and right iliac fossa pain helps facilitate timely diagnosis and exclusion of other differential diagnoses. Here, we present a rare cause which has significant medicolegal ramifications and is accurately diagnosed with CT.

An observational study investigating the effect of platelet function on outcome after colorectal surgery.

INTRODUCTION: Previous studies have assumed patients have uniform responses to aspirin, yet significant numbers are occult hypo- or hyper-responders. A new validated test of platelet function measures platelet P-selectin expression, which rises with increased platelet activity. This study investigated the measured perioperative changes in platelet function in response to aspirin, and subsequently whether quantitative variations in platelet activity affected perioperative complication severity and frequency. METHODS: 107 patients undergoing major colorectal surgery were recruited and assigned to either control (no antiplatelet therapy) or aspirin groups. P-selectin was measured following platelet stimulation at recruitment prior to cessation of medication, and at surgery before intervention. Perioperative complications, hemoglobin changes and blood transfusions were also recorded. RESULTS: Platelet function was higher in control (n = 87) than aspirin group (n = 20) at recruitment (median 1303u [IQR 1102-1499] vs 77u [IQR 63.5-113.5],P < 0.01) and surgery (median 1224u [IQR 944-1496] vs 281.5u [IQR 106.8-943], P < 0.01). There was a positive correlation between length of aspirin cessation and platelet function at surgery (R(S) = 0.66, P < 0.01). Complication rates and hemorrhagic complication rates (P < 0.05) were higher with aspirin than control, although complication severity was not increased. Platelet function of the entire cohort at surgery was not associated with complication rate, severity or transfusion use. DISCUSSION: Although complication rates were higher in aspirin group, impaired platelet function within ranges seen with aspirin continuation did not affect complication severity or rate or blood transfusion use. Consequently, aspirin continuation may not affect clinical outcome in patients undergoing major colorectal surgery and requires further investigation with a large randomized trial.

Is there a role for intravenous iron therapy in patients undergoing colorectal cancer resection?

Worldwide, colorectal cancer (CRC) is one of the most common forms of malignancy and is increasing in incidence in many regions. At diagnosis, approximately 40% of patients with CRC are anemic, a figure that increases over the course of a patient's treatment due to many factors, including ongoing hemorrhage. Preoperative anemia is therefore associated with increased allogenic red blood cell transfusion (ARBT) rates. In the context of CRC, perioperative ARBT has been linked with adverse postoperative outcomes, including higher morbidity, mortality and cancer recurrence rates. Therefore, strategies to potentially reduce the need for ARBT have been the focus of several recent studies. We critically evaluate a recent paper that explores intravenous iron III sucrose as a treatment option for the management of postoperative anemia in CRC patients. This study is a retrospective, observational case-controlled study that was designed to evaluate whether the use of postoperative intravenous iron reduces the incidence of ARBT following CRC resection.