Robotic colon surgery in obese patients: a systematic review and meta-analysis.

BACKGROUND: Colon cancer resection can be technically difficult in the obese (OB) population. Robotic surgery is a promising technique but its benefits remain uncertain in OB patients. The aim of this study is to compare OB versus non-obese (NOB) patients undergoing robotic colon surgery, as well as OB patients undergoing robotic versus open or laparoscopic colonic surgery. METHODS: A systematic review and meta-analysis was performed. Primary outcome measures included length of stay (LOS), surgical site infection (SSI) rate, complications, anastomotic leak and oncological outcomes. RESULTS: A total of eight studies were included, with five comparing OB and NOB patients undergoing robotic colon surgery included in meta-analysis. A total of 263 OB patients and 400 NOB patients formed the sample for meta-analysis. There was no significant difference between the two groups in operative time, conversion to open, LOS, lymph node yield, anastomotic leak and postoperative ileus. There was a trend towards a significant increase in overall complications and SSI in the OB group (32.3% OB versus 26.8% NOB for complications, 14.2% OB versus 9.9% NOB for SSI). The three included studies comparing surgical techniques were too heterogeneous to undergo meta-analysis. CONCLUSION: Robotic colon surgery is safe in obese patients, but high-quality prospective evidence is lacking. Future studies should report on oncological safety and the cost-effectiveness of adopting the robotic technique in these challenging patients.

Temporal determinants of tumour response to neoadjuvant rectal radiotherapy.

INTRODUCTION: In locally advanced rectal cancer, longer delay to surgery after neoadjuvant radiotherapy increases the likelihood of histopathological tumour response. Chronomodulated radiotherapy in rectal cancer has recently been reported as a factor increasing tumour response to neoadjuvant treatment in patients having earlier surgery, with patients receiving a larger proportion of afternoon treatments showing improved response. This paper aims to replicate this work by exploring the impact of these two temporal factors, independently and in combination, on histopathological tumour response in rectal cancer patients. METHODS: A retrospective review of all patients with rectal adenocarcinoma who received long course (≥24 fractions) neoadjuvant radiotherapy with or without chemotherapy at a tertiary referral centre was conducted. Delay to surgery and radiotherapy treatment time were correlated to clinicopathologic characteristics with a particular focus on tumour regression grade. A review of the literature and meta-analysis were also conducted to ascertain the impact of time to surgery from preoperative radiotherapy on tumour regression. RESULTS: From a cohort of 367 patients, 197 patients met the inclusion criteria. Complete pathologic response (AJCC regression grade 0) was seen in 46 (23%) patients with a further 44 patients (22%) having at most small groups of residual cells (AJCC regression grade 1). Median time to surgery was 63 days, and no statistically significant difference was seen in tumour regression between patients having early or late surgery. There was a non-significant trend towards a larger proportion of morning treatments in patients with grade 0 or 1 regression (p = 0.077). There was no difference in tumour regression when composite groups of the two temporal variables were analysed. Visualisation of data from 39 reviewed papers (describing 27379 patients) demonstrated a plateau of response to neoadjuvant radiotherapy after approximately 60 days, and a meta-analysis found improved complete pathologic response in patients having later surgery. CONCLUSIONS: There was no observed benefit of chronomodulated radiotherapy in our cohort of rectal cancer patients. Review of the literature and meta-analysis confirms the benefit of delayed surgery, with a plateau in complete response rates at approximately 60-days between completion of radiotherapy and surgery. In our cohort, time to surgery for the majority of our patients lay along this plateau and this may be a more dominant factor in determining response to neoadjuvant therapy, obscuring any effects of chronomodulation on tumour response. We would recommend surgery be performed between 8 and 11 weeks after completion of neoadjuvant radiotherapy in patients with locally advanced rectal cancer.

Utility of intra-operative flexible sigmoidoscopy to assess colorectal anastomosis: a systematic review and meta-analysis.

BACKGROUND: Anastomotic leak (AL) after colorectal resection leads to increased oncological and non-oncological, morbidity and mortality. Intra-operative assessment of a colorectal anastomosis with intra-operative flexible sigmoidoscopy (IOFS) has become increasingly prevalent and is an alternative to conventional air leak test. It is thought that intra-operative identification of an AL or anastomotic bleeding (AB) allows for immediate reparative intervention at the time of anastomosis formation itself. We aim to assess the available evidence for the use of IOFS to prevent complications following colorectal resection. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature between January 1980 and June 2020 was performed. Comparative studies assessing IOFS versus conventional air leak test were compared, and outcomes were pooled. RESULTS: A total of 4512 articles were assessed, of which eight were found to meet the inclusion criteria. A total of 1792 patients were compared; 884 in the IOFS arm and 908 in the control arm. IOFS was associated with an increase in the rate of positive leak test (odds ratio (OR) 5.21, P > 0.001), a decrease in AL (OR 0.45, P = 0.006) and a decrease in post-operative AB requiring intervention (OR 0.40, P = 0.037). CONCLUSION: In a non-randomized meta-analysis, IOFS increases the likelihood of identifying an anastomotic defect or bleeding intra-operatively. This allows for immediate intervention that decreases the rate of AL and AB. This adds impetus for performing routine IOFS after a left-sided colorectal resection with anastomosis and highlights the need for randomized controlled trial to confirm the finding.

Oncological safety of laparoscopic versus open colorectal cancer surgery in obesity: a systematic review and meta-analysis.

BACKGROUND: Colorectal cancer resection in the obese (OB) patients can be technically challenging. With the increasing adoption of laparoscopic surgery, the benefits remain uncertain. Hence, the aim of this study is to assess the short- and long-term outcomes of laparoscopic compared to open colorectal cancer resection in the OB patients. METHODS: A systematic review and meta-analysis was performed according to the PRISMA guidelines. The outcome measures were 5-year disease-free survival, overall survival, circumferential resection margin and local and distant recurrence. RESULTS: A total of 20 studies were included, with a total number of 6779 participants, of whom 1785 (26.3%) were OB and 4994 (73.7%) were non-obese (NOB) participants. The OB patients had higher R1 resection (OB 6.9% versus NOB 3.1%; P = 0.011) and lower mean number of lymph nodes harvested, with standard mean difference of -0.29; P = 0.023, favouring the NOB patients. However, there was no statistical difference for local (OB 2.8% versus NOB 3.4%) or distant recurrence (OB 12.9% versus NOB 15.2%) rate between the two cohorts. There was no difference in 5-year disease-free survival (OB 81% versus NOB 77.4%; odds ratio 1.25, P = 0.215) and overall survival (OB 89.4% versus NOB 87.9%; odds ratio 1.16, P = 0.572). Lastly, the OB group had higher mean total blood loss, total operative time and length of hospital stay when compared to NOB patients. CONCLUSION: From a pooled non-randomized study, laparoscopic colorectal cancer resection is safe in OB patients with equivalent long-term outcomes compared to NOB patients. However, there is a higher morbidity rate with an increased demand on hospital resources for the OB cohort.

KRAS mutation is associated with lung metastasis in patients with curatively resected colorectal cancer.

PURPOSE: Oncogene mutations contribute to colorectal cancer development. We searched for differences in oncogene mutation profiles between colorectal cancer metastases from different sites and evaluated these as markers for site of relapse. EXPERIMENTAL DESIGN: One hundred colorectal cancer metastases were screened for mutations in 19 oncogenes, and further 61 metastases and 87 matched primary cancers were analyzed for genes with identified mutations. Mutation prevalence was compared between (a) metastases from liver (n = 65), lung (n = 50), and brain (n = 46), (b) metastases and matched primary cancers, and (c) metastases and an independent cohort of primary cancers (n = 604). Mutations differing between metastasis sites were evaluated as markers for site of relapse in 859 patients from the VICTOR trial. RESULTS: In colorectal cancer metastases, mutations were detected in 4 of 19 oncogenes: BRAF (3.1%), KRAS (48.4%), NRAS (6.2%), and PIK3CA (16.1%). KRAS mutation prevalence was significantly higher in lung (62.0%) and brain (56.5%) than in liver metastases (32.3%; P = 0.003). Mutation status was highly concordant between primary cancer and metastasis from the same individual. Compared with independent primary cancers, KRAS mutations were more common in lung and brain metastases (P < 0.005), but similar in liver metastases. Correspondingly, KRAS mutation was associated with lung relapse (HR = 2.1; 95% CI, 1.2 to 3.5, P = 0.007) but not liver relapse in patients from the VICTOR trial. CONCLUSIONS: KRAS mutation seems to be associated with metastasis in specific sites, lung and brain, in colorectal cancer patients. Our data highlight the potential of somatic mutations for informing surveillance strategies.

Continuous wound infusion of local anesthetic for the control of pain after elective abdominal colorectal surgery.

PURPOSE: Local anesthetic wound infusion has been investigated in recent years as a potential alternative to standard analgesic regimens after major surgery. This study investigates the efficacy of a continuous wound infusion of ropivacaine in conjunction with best practice postoperative analgesia after midline laparotomy for abdominal colorectal surgery. METHODS: We performed a randomized, participant and outcome assessor-blinded, placebo-controlled trial on patients presenting for major abdominal colorectal surgery at our institution between December 2003 and February 2006. Patients were allocated to receive ropivacaine 0.54 percent or normal saline via a dual catheter Painbuster Soaker (I-Flow Corporation, OH, USA) continuous infusion device into their midline laparotomy wound for 72 hours postoperatively. RESULTS: A total of 310 patients were included in this study. The continuous wound infusion of ropivacaine after abdominal colorectal surgery conveys minimal benefit compared with saline wound infusion. No statistically significant difference could be shown for: pain at rest, morphine usage, length of stay, mobility, nausea, or return of bowel function. There was a small, statistically significant difference in mean pain on movement on Day 1 for the ropivacaine group (adjusted mean difference -0.6 (range, -1.08 to -0.13)). Although this trend continued on Days 2 and 3, the differences between groups were no longer statistically significant. CONCLUSIONS: Management of pain after major abdominal colorectal surgery is best achieved through adopting a multimodal approach to analgesia. Delivery of ropivacaine to midline laparotomy wounds via a Painbuster Soaker device is safe, but we have not demonstrated any significant clinical advantage over current best practice.

Maternal and fetal outcome after colectomy for fulminant ulcerative colitis during pregnancy: case series and literature review.

PURPOSE: Previous studies have reported high morbidity and mortality in mothers and their offspring after colectomy for ulcerative colitis during pregnancy. This study was designed to assess the maternal and fetal outcomes of pregnant females undergoing colectomy for ulcerative colitis in the current era. METHODS: A retrospective analysis was performed at our institution of all pregnant females undergoing operation for ulcerative colitis between 1980 and 2004. To compare this data to that of past literature, a MEDLINE search from 1951 to 2004 reviewed all cases reported on this topic. RESULTS: Between 1980 and 2004, five females underwent an operation at our institution for fulminant ulcerative colitis while pregnant. All five patients underwent subtotal colectomy with Brooke ileostomy. Postoperative maternal morbidity included a superficial wound infection and a small asymptomatic intra-abdominal abscess. All females had successful pregnancies, and no maternal or fetal deaths occurred. Two patients went on to have an ileal pouch-anal anastomosis, one had a completion proctectomy and end ileostomy, one is scheduled for an ileal pouch-anal anastomosis, and one patient is lost to follow-up. The literature review revealed 37 cases. The overall fetal and maternal mortality was 49 and 22 percent respectively. Postoperative maternal morbidity was reported in 24 percent. CONCLUSIONS: In contrast to historic data, the maternal and fetal mortality from our series was zero and maternal morbidity was low. Subtotal colectomy and Brooke ileostomy for ulcerative colitis during pregnancy is safe. A multidisciplinary team that includes a gastroenterologist, high-risk obstetrician, and experienced surgeon is necessary for an optimal outcome.

Stents or open operation for palliation of colorectal cancer: a retrospective, cohort study of perioperative outcome and long-term survival.

PURPOSE: Expandable, metallic stents provide a new modality of palliation for patients with noncurable metastatic colorectal adenocarcinoma. This study was designed to compare the use of expandable metallic stents as a palliative measure to traditional open surgical management, with particular reference to length of stay, and survival. METHODS: Patients admitted between 1997 and 2002 with left-sided (splenic flexure and distal), colorectal adenocarcinoma and nonresectable metastatic disease (Stage 4) were treated with expandable metal stents or open surgery (resection, bypass, or stoma). The group of patients having stents inserted were compared with regard to perioperative outcome and survival to those having open surgical procedures. RESULTS: Twenty-two of 25 patients had colonic stents successfully inserted and 19 patients underwent open surgery. The two groups were comparable: stent: median age, 66 (range, 37-88) years; 13 males; and open operation: median age, 68 (range, 51-85) years; 12 males. The tumors were primary in 22 stents procedures and 18 open operations. The site of obstruction was: splenic flexure, 2 stent vs. 0 open operation; descending colon, 2 stent vs. 2 open operation; sigmoid colon, 12 stent vs. 6 open operation; rectum, 9 stent vs. 11 open operation. The American Society of Anesthesiologists (ASA) class was: ASA 1, 0 stent vs. 0 open operation; ASA 2, 6 stent vs. 9 open operation; ASA 3, 15 stent vs. 7 open operation; ASA 4, 4 stent vs. 3 open operation. The open operations were laparotomy only (n = 2), bypass (n = 1), stoma (n = 7), resection with anastomosis (n = 4), resection without anastomosis (n = 5). The complications after open operation were urinary (n = 2), stroke (n = 1), cardiac (n = 2), respiratory (n = 2), deep vein thrombosis (n = 1), anastomotic leak (n = 1). There were no stent-related complications. The mean length of stay was significantly shorter in the stent group (4 vs. 10.4 days; P < 0.0001). There was no difference in survival between the two groups (median survival: stent group, 7.5 months; open operation, 3.9 months; log-rank P value = 0.2156). CONCLUSIONS: Patients treated with stents are discharged earlier than after open surgery. Stents do not affect survival. Expandable metal stents provide an acceptable alternative and may be better than traditional open surgical techniques.

Abdominoperineal resection or low Hartmann's procedure.

AIM: To compare patients having low Hartmann's resection (LHP) with abdominoperineal resection (APR) by investigating postoperative complications. METHODS: Retrospective comparative analysis of preoperative state and postoperative course for patients having surgery from 1 January 1997 to 1 July 2001, by the surgeons of the Colorectal Unit, Christchurch Hospital, Christchurch, New Zealand. RESULTS: Over a 54-month period 65 patients underwent either LHP or APR (29 LHP, 36 APR). The median age/sex (male:female) of patients for LHP was 76 years (51-90 years) (14:15), for APR 72 years (31-93 years) (19:17). The indication for surgery was predominantly cancer (LHP 89.6%, APR 94.4%). There was a high rate of preoperative comorbidities: LHP 75.9% (cardiac 62.1%, pulmonary 17.2%), APR 75% (cardiac 50%, pulmonary 15.9%). Preoperative chemoradiation was used in 10.3% of patients having LHP and 30.6% with APR. There was no difference in postoperative non-septic complications. There was a significant difference in the types of septic complications (P = 0.018), with a higher rate of pelvic abscesses after LHP (5). Perineal wound infection occurred in five patients having APR (14.3%). The median time to heal a perineal wound was 1 month (0.5-7 months). The median length of stay was 13 days for LHP (5-33 days) and 11 days for APR (6-19 days) (P = 0.0266). CONCLUSION: This non-randomized, retrospective, cohort study shows a surprisingly high rate of pelvic abscesses after LHP compared with APR. Perineal wound healing was a problem after APR, but less of a management problem than the septic complications after LHP. Both LHP and APR might be associated with significant morbidity. A high pelvic abscess rate following LHP is associated with a high likelihood of further surgical intervention and a prolonged length of stay.

Technical aspects of ileoanal pouch surgery.

Ileal pouch-anal anastomosis has become the surgical procedure of choice for chronic ulcerative colitis. Since the initial description of the technique, various modifications have facilitated its evolution into a safe operation with excellent long-term outcomes. However, some aspects of the operation remain contentious. Our aim is to describe the technical aspects of ileal pouch-anal anastomosis and review the current literature in the areas of controversy.

Parastomal hernia following minimally invasive stoma formation.

BACKGROUND: Minimally invasive intestinal stoma formation using a laparoscopic approach or through a trephine, is widely described in published literature. The incidence of parastomal hernia (PH) following a stoma formed without formal laparotomy is not well reported. The present review aims to assess the current data available on minimally invasive stoma formation, with particular reference to the incidence of PH. METHODS: A literature search using the Pubmed Medline database was performed, locating English language articles on minimally invasive stoma formation from 1970 to 2002. The manuscripts were searched manually for further references. RESULTS: The number of published studies describing laparoscopic stoma formation is small (263 stomas) and the follow-up studied were short (none longer than 1 year). The incidence of PH was 0-6.7%. The incidence following a trephine stoma was 6.7-12%, and the number of patients was small (118) and the follow up short (up to 12 months). CONCLUSIONS: The incidence of PH following minimally invasive stoma formation using a trephine or a laparoscopic technique remains unclear. Studies published to date are generally small and the follow up is short. A prospective randomized trial comparing minimally invasive stoma formation with stoma formation with laparotomy, is required.

Radical lymph node dissection for melanoma.

BACKGROUND: Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity. The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit. METHODS: The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001. RESULTS: The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P < 0.02). Multivariate analysis identified inguinal RLND (P = 0.002) and increasing tumour size (P = 0.045) as predictors of wound morbidity. More patients received postoperative radiotherapy after neck RLND compared to inguinal or axilla RLND (P = 0.03). Six (8%) patients developed local recurrence after lymphadenectomy. At a median follow up of 22 months, 34 (53%) patients have died, from disseminated disease. CONCLUSIONS: Radical lymphadenectomy for melanoma is associated with significant morbidity. Inguinal node dissection has a higher rate of complications than axillary dissection. Low local recurrence rates can be achieved, limiting the potential morbidity of uncontrolled regional metastatic disease.