Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework.

AIMS: Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients. METHOD: A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site). RESULTS: Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient). CONCLUSIONS: The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.

Physiological changes after colorectal surgery suggest that anastomotic leakage is an early event: a retrospective cohort study.

AIM: Anastomotic leakage (AL) is often identified 7-10 days after colorectal surgery. However, in retrospect, abnormalities may be evident much earlier. This study aims to identify the clinical time point when AL occurs. METHOD: This is a retrospective case-matched cohort comparison study, assessing patients undergoing left-sided colorectal resection between 2006 and 2015 at a specialist colorectal unit. Patients who developed AL (LEAK) were case-matched to two CONTROL patients by procedure, gender, laparoscopic modality and diverting stoma. Case note review allowed the collection of basic observation data and blood tests (leukocyte count, C-reactive protein, bilirubin, alanine transaminase, creatinine) up to postoperative day (POD) 4. The cohorts were compared, with the main outcome measure being changes in basic observation data. RESULTS: Of 554 patients, 49 developed AL. These were matched to 98 CONTROL patients. Notes were available for 105 patients (32 LEAK/73 CONTROL). Groups were similar in demographics, tumour or nodal status, preoperative radiotherapy, intra-operative air-leak integrity and drain usage. AL was detected clinically at a median of 7.5 days postoperatively. There was a significantly increased heart rate by the evening on POD 1 in LEAK patients (82.8 ± 14.2/min vs 75.1 ± 12.7/min, P = 0.0081) which persisted for the rest of the study. By POD 3, there was a significant increase in respiratory rate (18.0 ± 4.2/min vs 16.5 ± 1.3/min, P = 0.0069) and temperature (37.0 ± 0.4C vs 36.7 ± 0.3C, P = 0.0006) in LEAK patients. C-reactive protein was significantly higher in LEAK patients from POD 2 (165 ± 95 mg/l vs 121 ± 75 mg/l, P = 0.023). CONCLUSIONS: Physiological and biochemical changes associated with AL happen very early postoperatively, suggesting that AL may occur within 36 h after surgery, despite much later clinical detection.

Long-term outcome of laparoscopic rectopexy for full-thickness rectal prolapse.

BACKGROUND: The aim of this study was to assess the long-term outcomes of laparoscopic rectopexy for full-thickness rectal prolapse (FTRP). METHODS: Data of a prospectively maintained database were analysed. A structured telephone interview was conducted to assess a consecutive series of long-term outcomes of an unselected population who had laparoscopic rectopexy at a single centre between April 2006 and April 2014. The primary outcome was recurrence of FTRP. Secondary outcomes were functional outcomes and morbidity associated with the procedure. RESULTS: A total of 80 patients (74 female, median age of 66 years, range 23-96 years) underwent a laparoscopic rectopexy, of whom 35 (44%) were for recurrent prolapse. Seventy-two patients (90%) had a posterior suture rectopexy, six (8%) had a ventral mesh rectopexy, one (1%) had a combination of both procedures, and one (1%) had a posterior suture rectopexy with a sacrocolpopexy. There was no conversion to open surgery. Three patients (4%) needed reoperation within 30 days after surgery: two due to small bowel obstruction and one for a suspected port site hernia. Seventy-four patients (93%) were available for either clinical follow-up (FU) or telephone interview and there were 17 (23%) recurrences of FTRP at the median FU of 57 months (range 1-121 months). The median time to recurrence was 12 months (range 1-103 months). Recurrence of FTRP was seen in nine patients (12%) within 1 year following surgery. A history of multiple previous prolapse repairs increased the risk of prolapse recurrence (odds ratio 8.33, 95% confidence interval 1.38-50.47, p = 0.020). Based on clinical follow-up of 71 patients up to 1 year, there were 41 patients (58%) who had faecal incontinence prior to rectopexy of whom two patients (5%) had complete resolution of symptoms and 14 (34%) had improvement. CONCLUSIONS: Laparoscopic rectopexy is a safe operation for full-thickness rectal prolapse. The durability of the repair diminished over time, particularly for patients operated on for recurrent prolapse.

Anastomotic leaks can be detected within 5 days following ileorectal anastomosis: a case-controlled study in patients with familial adenomatous polyposis.

AIM: To determine the earliest time point at which anastomotic leaks can be detected in patients undergoing total colectomy with primary ileorectal anastomosis for familial adenomatous polyposis. METHOD: This was a case-controlled study of 10 anastomotic leak patients vs 20 controls following laparoscopic total colectomy with ileorectal anastomosis for familial adenomatous polyposis (from 96 consecutive patients between 2006 and 2013). Panel time-series data regression was performed using a double subscript structure to include both variables. A generalized least squares multivariate approach was applied in a random effects setting to calculate correlations for observations, with anastomotic leak being the dependent variable. Univariate and multivariate regression calculations were then performed according to individual observations at each recorded time point. Time-series analysis was used to determine when a variable became significant in the leak group. RESULTS: Multivariate analysis identified a significant difference between leak and control groups in mean heart rate (P < 0.001), mean respiratory rate (P = 0.017) and mean urine output (P = 0.001). Time-point analysis showed that heart rate was significantly different between leak and control groups at postoperative day 4.25. Multivariate analysis identified a significant difference between groups in alanine transaminase (P = 0.006), bilirubin (P = 0.008), creatinine (P = 0.001), haemoglobin (P < 0.001) and urea (P = 0.007). There were no differences between groups with regard to markers of inflammation such as albumin, white blood cell count, neutrophil count and C-reactive protein. CONCLUSION: Anastomotic leaks can be detected early (within 4.5 days of surgery) through changes in physiological, blood test and observational parameters, providing an opportunity for early intervention in these patients to salvage the anastomosis.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery.

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer.

BACKGROUND: Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality. METHODS: MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data. RESULTS: Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy. CONCLUSION: Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).

Outcomes following laparoscopic rectal cancer resection by supervised trainees.

BACKGROUND: The aim was to evaluate the applicability of laparoscopic surgery in the treatment of primary rectal cancer in a training unit. METHODS: A cohort analysis was undertaken of consecutive patients undergoing elective surgery for primary rectal cancer over a 7-year interval. Data on patient and operative details, and short-term clinicopathological outcomes were collected prospectively and analysed on an intention-to-treat basis. RESULTS: A total of 306 patients (213 men, 69·6 per cent) of median (i.q.r.) age 67 (58-73) years with a median body mass index of 26·6 (23·9-29·9) kg/m(2) underwent surgery. Median tumour height was 8 (6-11) cm from the anal verge, and 46 patients (15·0 per cent) received neoadjuvant radiotherapy. Seven patients (2·3 per cent) were considered unsuitable for laparoscopic surgery and underwent open resection; 299 patients (97·7 per cent) were suitable for laparoscopic surgery, but eight were randomized to open surgery as part of an ongoing trial. Some 291 patients (95·1 per cent) underwent a laparoscopic procedure, with conversion required in 29 (10·0 per cent). Surgery was partially or completely performed by trainees in 72·4 per cent of National Health Service patients (184 of 254), whereas private patients underwent surgery primarily by consultants. Median postoperative length of stay for all patients was 6 days and the positive circumferential resection margin rate was 4·9 per cent (15 of 306). CONCLUSION: Supervised trainees can perform routine laparoscopic rectal cancer resection.

Influence of body composition profile on outcomes following colorectal cancer surgery.

BACKGROUND: Muscle depletion is characterized by reduced muscle mass (myopenia), and increased infiltration by intermuscular and intramuscular fat (myosteatosis). This study examined the role of particular body composition profiles as prognostic markers for patients with colorectal cancer undergoing curative resection. METHODS: Patients with colorectal cancer undergoing elective surgical resection between 2006 and 2011 were included. Lumbar skeletal muscle index (LSMI), visceral adipose tissue (VAT) surface area and mean muscle attenuation (MA) were calculated by analysis of CT images. Reduced LSMI (myopenia), increased VAT (visceral obesity) and low MA (myosteatosis) were identified using predefined sex-specific skeletal muscle index values. Univariable and multivariable Cox regression models were used to determine the role of different body composition profiles on outcomes. RESULTS: Some 805 patients were identified, with a median follow-up of 47 (i.q.r. 24·9-65·6) months. Multivariable analysis identified myopenia as an independent prognostic factor for disease-free survival (hazard ratio (HR) 1·53, 95 per cent c.i. 1·06 to 2·39; P = 0·041) and overall survival (HR 1·70, 1·25 to 2·31; P < 0·001). The presence of myosteatosis was associated with prolonged primary hospital stay (P = 0·034), and myopenic obesity was related to higher 30-day morbidity (P = 0·019) and mortality (P < 0·001) rates. CONCLUSION: Myopenia may have an independent prognostic effect on cancer survival for patients with colorectal cancer. Muscle depletion may represent a modifiable risk factor in patients with colorectal cancer and needs to be targeted as a relevant endpoint of health recommendations.

An analysis of the accuracy of computed tomography colonography when defining anatomy for novel full-thickness colonic excision techniques in early colonic neoplasia.

AIM: Full-thickness laparo-endoscopic excision (FLEX) is a new technique developed for the full-thickness excision of colonic adenomas and, potentially, early cancer, avoiding the need for colectomy. FLEX requires accurate preoperative characterization of three key morphological features of the tumour, including its relation to the mesenteric border, its diameter and the circumferential extent of involvement of the bowel wall. This study evaluated the accuracy of CT colonography (CTC) for the assessment of these features in early colonic tumours. METHOD: Consecutive patients undergoing CTC prior to colonic resection for complex benign polyps or UICC Stage 1 cancer were retrospectively analysed by two specialist gastrointestinal radiologists blinded to the subsequent histopathological findings. The location of the tumour in relation to the mesenteric border, its maximum diameter and the circumferential extent of involvement of the colonic wall were correlated with the histopathological examination of the surgical resection specimen. Pearson's correlation coefficient (r) and Kappa agreement (κ) were used to compare the maximum diameter and the circumferential extent of involvement of the colonic wall. RESULTS: Twenty-eight patients with early colonic neoplasia were included. All had had a surgical segmental resection. Four had a benign adenoma and 24 had a TNM Stage 1 cancer. Histopathological assessment of the resected surgical specimen showed that 21 of the 28 lesions were located on the mesenteric border. The median diameter was 35 (interquartile range 28-42) mm; 13 lesions involved less than one-third of the circumference, 11 between one and two-thirds and four more than two-thirds. CTC correctly identified the location of the lesion in relation to the mesenteric border in all 28 cases. Correlation between CTC and histopathology was good for the assessment of the maximum diameter of the lesion (r = 0.81) and the circumferential extent of involvement of the colonic wall (κ = 0.76). CONCLUSION: CTC can accurately assess the key morphological features for the selection of patients with early colonic neoplasia for full-thickness laparo-endoscopic excision.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice.

BACKGROUND: The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. METHODS: Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English-language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. RESULTS: This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. CONCLUSIONS: Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi-institutional prospective and adequately powered randomized trials.

Systematic review of surgical innovation reporting in laparoendoscopic colonic polyp resection.

BACKGROUND: The IDEAL framework (Idea, Development, Exploration, Assessment, Long-term study) proposes a staged assessment of surgical innovation, but whether it can be used in practice is uncertain. This study aimed to review the reporting of a surgical innovation according to the IDEAL framework. METHODS: Systematic literature searches identified articles reporting laparoendoscopic excision for benign colonic polyps. Using the IDEAL stage recommendations, data were collected on: patient selection, surgeon and unit expertise, description of the intervention and modifications, outcome reporting, and research governance. Studies were categorized by IDEAL stages: 0/1, simple technical preclinical/clinical reports; 2a, technique modifications with rationale and safety data; 2b, expanded patient selection and reporting of both innovation and standard care outcomes; 3, formal randomized controlled trials; and 4, long-term audit and registry studies. Each stage has specific requirements for reporting of surgeon expertise, governance details and outcome reporting. RESULTS: Of 615 abstracts screened, 16 papers reporting outcomes of 550 patients were included. Only two studies could be put into IDEAL categories. One animal study was classified as stage 0 and one clinical study as stage 2a through prospective ethical approval, protocol registration and data collection. Studies could not be classified according to IDEAL for insufficient reporting details of patient selection, relevant surgeon expertise, and how and why the technique was modified or adapted. CONCLUSION: The reporting of innovation in the context of laparoendoscopic colonic polyp excision would benefit from standardized methods.

Morphometric analysis and lymph node yield in laparoscopic complete mesocolic excision performed by supervised trainees.

BACKGROUND: Complete mesocolic excision with central vascular ligation (CME) produces an optimal colonic cancer specimen. The ability of expert laparoscopic surgeons to produce equivalent specimens is unknown. METHODS: Fresh specimen photographs and clinicopathological data from patients undergoing laparoscopically assisted CME at St Mark's Hospital, Harrow, were submitted for independent pathological review. Surgery was performed by a mixture of consultant specialists and trainees under consultant specialist supervision, between February 2010 and July 2011. The planes of surgery were graded and tissue morphometry was performed using standard methods. The results were compared with published data from open CME and non-CME surgery. RESULTS: In total, 69 patients were identified, and in 96 per cent resection was performed completely or partially by surgical trainees. Laparoscopic CME produced a similar specimen to open CME. The laparoscopic mesocolic plane resection rate was similar to that for open surgery (90 versus 88 per cent). The distance between the bowel wall and site of vascular division was similar for laparoscopic and open right-sided CME (92 versus 95 mm respectively). The corresponding values for left-sided CME were also similar (103 versus 107 mm). Compared with values from two non-CME series, laparoscopic CME had a higher mesocolic plane rate (90 versus 40 and 48 per cent), and resected more tissue between the bowel wall and the vascular division (right-sided: 92 versus 72 and 76 mm; left-sided: 103 versus 85 and 70 mm). The lymph node yield remained low following laparoscopic CME compared with open CME (median 18 versus 32; P < 0·001) and identical to that of non-CME surgery (median 18). CONCLUSION: Laparoscopic CME can be performed to the same standard as open surgery by supervised trainees. However, this did not increase the lymph node yield.

Outcomes of laparoscopic and open restorative proctocolectomy.

BACKGROUND: The literature on laparoscopic restorative proctectomy (RP) and proctocolectomy (RPC) is limited. This study compared clinical outcomes of laparoscopic RP and RPC with those of conventional open surgery at one centre. METHODS: Data were analysed from consecutive patients undergoing RPC and RP between November 2006 and November 2011. A standard laparoscopic technique was developed during the first 2 years, performed by two laparoscopic surgeons, with selection of patients who had not previously undergone open colectomy. Study endpoints included postoperative length of stay, 30-day morbidity, readmission, reoperation, pouch function and failure. RESULTS: A total of 207 patients were included; open surgery was performed in 131 (63·3 per cent) and a laparoscopic procedure in 76 (36·7 per cent). There were no significant differences in patient demographics. The conversion rate was 9 per cent (7 of 76). The median (i.q.r.) duration of operation was shorter for open than for laparoscopic procedures: 208 (178-255) versus 285 (255-325) min respectively (P < 0·001). Laparoscopic RPC had a shorter length of stay: median (i.q.r.) 6 (4-8) versus 8 (7-12) days (P < 0·001). The rate of minor complications was lower in the laparoscopic group (33 versus 50·4 per cent; odds ratio (OR) 0·48, 95 per cent confidence interval 0·27 to 0·87).There were no significant differences in total complications (51 per cent after laparoscopy versus 61·5 per cent after open surgery; OR 0·66, 0·37 to 1·17), anastomotic leakage, major morbidity, 30-day readmission, reoperation and stoma closure rates. Pouch failure (including permanent stoma) occurred in 14 (7·7 per cent) of 181 patients. Three patients died, all in the open surgery group. CONCLUSION: Laparoscopic RPC is feasible with some short-term advantages.

The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery : proceedings of a consensus conference.

BACKGROUND: It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors. METHOD: There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction. RESULT: The oncological rationale for CME and various technical aspects of the surgical management will be explored. CONCLUSION: The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.

A prospective case controlled study of the short-term outcome following hemicolectomy for benign compared with malignant colonic polyps.

AIM: The number of patients diagnosed with advanced colonic polyps has increased due to screening. The outcome of hemicolectomy for benign lesions is poorly documented. We present a case-matched study comparing the results of hemicolectomy for benign and malignant polyps performed in two institutions. METHODS: Data for consecutive patients undergoing surgery for benign colonic polyps (BCPs) were prospectively collected in two hospitals. Each patient was matched for age, sex, ASA grade, site and type of resection (laparoscopic, open and converted) with two controls who underwent surgery for colon cancer (CC). The length of stay (LOS) and 30-day outcome were analysed adjusting for potential confounders. Multilevel linear and logistic regression analyses were performed. RESULTS: Forty-six patients having hemicolectomy for BCP were matched with 81 patients with CC. The median size of BCP was 4 cm [interquartile range (IQR) 2.5-5.4 cm]. Patients with a BCP had a marginally longer LOS [median 5.5 (IQR 4-8) days and 5 (IQR 3-7) days (P = 0.04)]. Twenty-one (46%) of 46 patients with BCP had a postoperative complication compared with 25 (31%) of 81 CC patients (P = 0.12, OR = 2.11, 95% CI 0.82-5.41). Four (9%) of 46 patients with BCP underwent re-operation and a further three (7%) were readmitted compared with one (1%) and two (2%) of 81 patients with CC (P = 0.07 and 0.28). There was no mortality in either group. CONCLUSION: Complications following hemicolectomy for BCP or CC are not significantly different. The results of the study provide further impetus to develop local full thickness colonic excision for benign colonic lesions as an alternative to major surgery.

A systematic review of enhanced recovery care after colorectal surgery in elderly patients.

AIM: Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old. METHOD: A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence. RESULTS: Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations. CONCLUSION: ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.

Impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery.

AIM: Chronic kidney disease (CKD) is increasing in prevalence and is associated with cardiovascular events and mortality in asymptomatic and vascular surgery populations. This study aimed to determine the role of CKD in stratifying peri- and postoperative risk for colorectal cancer (CRC) patients with nonmetastatic disease undergoing elective curative resection. METHOD: Patients diagnosed with nonmetastatic colorectal adenocarcinoma and undergoing surgical resection between 2006 and 2011 were identified from a prospectively collated database. Further information on survival and cause of death was gathered from a regional cancer registry. Estimated glomerular filtration rates were calculated using the Modification of Diet in Renal Disease (MDRD) equation. Kaplan-Meier survival curves were constructed for disease-free and overall survival. Multivariate Cox regression models were used to determine the role of CKD after stratification by several clinicopathological factors. RESULTS: Seven-hundred and eight colorectal resections were studied [median follow up: 45 (interquartile range, 21-65) months). Overall postoperative complications were similar, but patients with CKD were more likely to develop cardiovascular morbidity (P < 0.001) and 30-day mortality [4.8% (six of 124) in the CKD group vs 2.1% (12/580) in the non-CKD group]. Kaplan-Meier analysis revealed poorer overall survival for localized (Stage I-II; P = 0.019) and Stage III (P = 0.001) CRC in the CKD population. Multivariate Cox regression analysis identified CKD as an independent prognostic factor for noncancer death [hazard ratio (HR) = 1.82 (95% CI: 1.07-3.10); P = 0.027] but not for overall survival [HR = 1.21 (95% CI: 0.90-1.47); P = 0.116]. CONCLUSION: Patients with CKD may be more likely to develop cardiovascular complications following CRC resection and have an increased risk of a noncancer death. Future research should explore the interaction of CKD in competing mortality risks following CRC surgery.

Full-thickness laparoendoscopic colonic excision in an experimental model.

BACKGROUND: Patients requiring surgery for complex colonic polyps traditionally undergo colectomy, with significant risks. Typically in excess of 10-30 cm of colon is removed at laparoscopic or open surgery lasting over 60 min. This study details the preclinical development of a rapid, minimally invasive, limited full-thickness colonic resection. METHODS: Both survival and non-survival procedures were performed in anaesthetized 70-kg pigs. A simulated colonic polyp was created by endoscopic ink injection with a clearance margin delineated by circumferential placement of mucosal argon plasma coagulation marks. Full-thickness eversion of the bowel was achieved using endoscopically placed anchors and the polyp was excised using a laparoscopic stapler. In survival procedures, pigs were killed under anaesthetic 8 days after surgery. All pigs underwent post-mortem examination. RESULTS: Five procedures were performed (5 pigs). The median (range) procedure duration was 26 (20-31) min, with a specimen diameter of 5.1 (4.5-6.3) cm. The postoperative recovery of survival animals (4 pigs) was uneventful. At post-mortem evaluation the resection sites were well healed with no evidence of stenosis, intra-abdominal infection or inadvertent organ damage. Histological assessment of anastomoses showed mucosal repair and restoration of submucosal continuity. CONCLUSION: Full-thickness localized colonic excision with this technique provides a large specimen with adequate healing in a porcine model.

Requirement for postoperative imaging in an enhanced recovery programme.

AIM: Enhanced recovery after surgery (ERAS) produces benefits to patients by reducing the length of hospital stay and morbidity. Its effect on nursing and physiotherapy workload has been studied, but the demand upon radiology is unclear. We aimed to determine radiology use to understand possible hidden expenditure not included in existing ERAS cost-effectiveness analyses. METHOD: Two-hundred and sixty-five patients from a prospective multidimensional ERAS database were retrospectively assessed for postoperative radiology use. All had undergone colorectal surgery within an established ERAS programme from 2008 to 2009, with all data prospectively recorded. Laparoscopy was offered for all primary colon and rectal resections. All adverse events, including gut dysfunction, surgical site infection and reoperation, were assessed. All radiology within 30 days of surgery was recorded. RESULTS: Radiology data were absent in 12 patients, leaving 253 for analysis. Postoperative radiology was used in 71 (28%) patients, and 41 (16%) had CT of the abdomen and pelvis (A/P) within 30 days of surgery. In 33 (13%) patients this was required during the primary admission, including 30% of patients with any postoperative adverse event. Nine (27%; 3.6% of the whole cohort) of the 33 patients required reoperation. No patient required interventional radiology. The median time to CT (A/P) during primary admission was 5 (interquartile range, 3-8) days. Eight (3%) patients had CT (A/P) after readmission with one reoperation. Forty (16%) patients underwent plain radiology (chest or abdominal) and six (2%) had abdominal ultrasound. Using general estimates of CT and plain radiology total costs, these data suggest an overall radiology cost of over £22,000, amounting to a radiology cost of £90 per ERAS patient. CONCLUSION: Postoperative radiology is required in a significant proportion of ERAS patients, potentially reflecting a low threshold to investigate in the presence of an adverse event. Very few require subsequent intervention. Radiology costs incurred with ERAS should be considered in future economic analyses.

Early prediction of adverse events in enhanced recovery based upon the host systemic inflammatory response.

AIM: Early identification of patients experiencing postoperative complications is imperative for successful management. C-reactive protein (CRP) is a nonspecific marker of inflammation used in many specialties to monitor patient condition. The role of CRP measurement early in the elective postoperative colorectal patient is unclear, particularly in the context of enhanced recovery (ERAS). METHODS: Five hundred and thirty-three consecutive patients who underwent elective colorectal surgery between October 2008 and October 2010 within an established ERAS programme were studied. Patients were separated into a development group of 265 patients and a validation group of 268 patients by chronological order. CRP and white cell count were added to a prospectively maintained ERAS database. The primary outcome of the study was all adverse events (including infective complications, postoperative organ dysfunction and prolonged length of stay) during the initial hospital admission. Significant predictors for adverse events on univariate analysis were submitted to multivariate regression analysis and the resulting model applied to the validation group. The validity and predictive accuracy of the regression model was assessed using receiver operating characteristic curve/area under the curve (AUC) analysis. RESULTS: CRP levels >150 mg/l on postoperative day 2 and a rising CRP on day 3 were independently associated with all adverse events during the hospital admission. A weighted model was applied to the validation group yielding an AUC of 0.65 (95% CI 0.58-0.73) indicating, at best, modest discrimination and predictive accuracy for adverse events. CONCLUSION: Measurement of CRP in patients after elective colorectal surgery in the first few days after surgery within ERAS can assist in identifying those at risk of adverse events and a prolonged hospital stay. A CRP value of >150 mg/l on day 2 and a rising CRP on day 3 should alert the surgeon to an increased likelihood of such events.