Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study.

AIM: Frailty is defined as a decrease in physiological reserve with increased risk of morbidity following significant physiological stressors. This study examines the predictive power of the five-item modified frailty index (5-mFI) in predicting outcomes in colorectal surgery patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database was queried from 2011 to 2016 to determine the predictive power of 5-mFI in patients who had colorectal surgery. RESULTS: Of 295 490 patients, 45.8% had a score of 0, 36.2% had a score of 1 and 18% had a score of ≥ 2. On univariate analysis, frailer patients had significantly greater incidences for overall morbidity, serious morbidity, mortality, prolonged length of hospital stay, discharge to a facility other than home, reoperation and unplanned readmission. These findings were consistent on multivariate analysis where the frailest patients had greater odds of postoperative overall morbidity (OR 1.39; 95% CI 1.35-1.43), serious morbidity (OR 1.39; 95% CI 1.33-1.45), mortality (OR 2.00; 95% CI 1.87-2.14), prolonged length of hospital stay (OR 1.24; 95% CI 1.20-1.27), discharge destination to a facility other than home (OR 2.80; 95% CI 2.70-2.90), reoperation (OR 1.17; 95% CI 1.11-1.23) and unplanned readmission (OR 1.31; 95% CI 1.26-1.36). Weighted kappa statistics showed strong agreement between the 5-mFI and 11-mFI (kappa = 0.987, P < 0.001). CONCLUSIONS: The 5-mFI is a valid and easy to use predictor of 30-day postoperative outcomes after colorectal surgery. This tool may guide the surgeon to proactively recognize frail patients to instigate interventions to optimize them preoperatively.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome.

AIM: Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. METHOD: A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed. RESULTS: Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001). CONCLUSION: Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Prospective analysis of the sealing ability of the ENSEAL® G2 Articulating Tissue Sealer and transector on human mesenteric vessels in colorectal surgery.

BACKGROUND: The sealing and transection of mesenteric vessels is a crucial step in minimally invasive colorectal surgery. We examined the sealing quality of the ENSEAL® G2 Articulating Tissue Sealer in three different articulations in mesenteric vessels. METHODS: This was a prospective experimental study within a tertiary healthcare center, and 30 patients were recruited. Burst pressures for each specimen were measured as the primary outcome. Ten specimens at each of the three articulations were also histologically assessed for the quality of seal. RESULTS: We evaluated 54 sets of specimens from 30 patients for bursting pressure, all of which were harvested and sealed in the operating room. No statistical difference was seen in burst pressures from seals recorded at no angulation, half-maximal angulation, or maximal angulation (1604, 1507, 1478 mmHg; p = 0.07). Histological analysis showed no statistical differences in the average vessel diameter (p = 0.57), lateral extent of thermal injury (p = 0.48), degree of vascular sclerosis, or the integrity of seal at the three articulations. No cases of intraoperative or postoperative bleeding were observed in any of the patients. Five (16.7%) of the ENSEAL® devices developed breaks in the black, heat-shrink, polyethylene covering as a result of repeated articulation and disarticulation. Electrical arcing did not appear to have occurred as a result of the break, although this was not formally examined. CONCLUSIONS: The maximum sustainable pressure in mesenteric vessels sealed with a bipolar electrothermal device is supraphysiological, and consequently, the device can be safely used at various articulations to seal vessels during colorectal surgery.

Transverse incision transvaginal rectocele repair combined with levatorplasty and biological graft insertion: technical details and case series outcomes.

BACKGROUND: The purpose of this report is twofold: first, to detail our operative approach to rectocele repair, and second, to report on the outcomes. METHODS: Transverse incision transvaginal rectocele repair combined with levatorplasty and biological graft placement is detailed using hand-drawn sketches and intraoperative photographs. All patients with symptoms of functional constipation and non-emptying rectocele operated on from May 2007 to March 2013 at our institution were enrolled in this study. Data from a prospectively maintained database were retrospectively analyzed. Preoperative and postoperative functional outcomes were studied using a validated 31-point obstructed defecation (OD) scoring system. Follow-up was 1 year. RESULTS: Twenty-three patients underwent the procedure. The mean age of patients was 55 years (range 28-79 years). The OD severity score improved from the preoperative mean of 21.6 to postoperative mean of 5.5 (p = 0.001). Three out of four patients with initial symptoms of dyspareunia (75%) reported significant improvement in dyspareunia, while 2 out of 19 patients without initial symptoms of dyspareunia (11%) reported mild dyspareunia following the repair. One patient (4%) required operative drainage of a hematoma. Another patient (4%) developed symptomatic recurrence which was confirmed radiologically. CONCLUSIONS: In properly selected patients, the technique described leads to significant improvement in symptoms of OD and low recurrence without an increased rate of dyspareunia.

Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection?

AIM: The aim of the study was to evaluate the value of routine intra-operative flexible sigmoidoscopy (IOFS) for left-sided anastomotic integrity and to determine the safest step after a positive leak test. METHOD: All consecutive patients undergoing left-sided colorectal resections for benign and malignant disease between August 2005 and April 2011 were included. Data regarding procedure, type of anastomosis and outcomes of IOFS were collected. A positive intra-operative leak test resulted in redoing the anastomosis and repeating the leak test. RESULTS: A total of 415 consecutive patients underwent hand-assisted laparoscopic colorectal resection with a colorectal/ileoanal anastomosis. All patients underwent IOFS. Seventeen patients had abnormality on IOFS. Fifteen patients had a positive air leak test. One patient had anastomotic bleeding. There was one stapler misfiring. Fourteen anastomoses were redone without diversion. One patient required diversion to protect the ileoanal anastomosis and another had already been diverted. Minor bleeding from the staple line in one patient resolved without intervention; however, he had a postoperative anastomotic leak needing surgical intervention. None of the patients who had a takedown and refashioning of the anastomosis following a positive leak on IOFS had postoperative anastomotic leakage or bleeding. Our overall anastomotic leak rate was 2.1%. CONCLUSIONS: Intra-operative flexible sigmoidoscopy for restorative colorectal resection is safe and reliable and should be performed routinely to assess anastomotic integrity and bleeding. Refashioning the anastomosis after formal takedown would obviate the risk of leakage and is our recommended method of managing intra-operative leaks.

Is hybrid robotic laparoscopic assistance the ideal approach for restorative rectal cancer dissection?

AIM: While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors' preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra-operative and short-term outcomes. METHOD: Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intra-operative and short-term outcomes were evaluated. RESULTS: The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and nine had a coloanal pull-through procedure (mean age 60.1 years; mean body mass index 28.0 kg/m(2) ; mean operative time 327 min; conversion rate 3.9%). Three patients (3.9%) had positive resection margins (one circumferential, two distal). Five patients had an anastomotic leak (6.4%). No robot-specific complications were observed. CONCLUSION: The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection.

A lifelike patient simulator for teaching robotic colorectal surgery: how to acquire skills for robotic rectal dissection.

BACKGROUND: The use of robotic systems for colorectal resections is well documented, but robotic surgery is not yet established as a substitute for all laparoscopic colorectal procedures. The features of the new-generation robotic system seem to be well suited for proper mesorectal excision, with the identification and preservation of autonomic pelvic nerves. Proper training in the use of robotic skills is essential. METHODS: This report describes the creation of a pelvic model that can be used to teach the complex skills needed for successful completion of robotic rectal dissection. The model was designed to be cost effective, portable, and reusable in multiple teaching programs. Both the setup and size of the trainer were designed to be the same as those for a real patient and to allow for proper simulation of port placement in a true robotic rectal dissection. The operative field was molded directly onto a replica of a human skeleton, and the materials that make up the trainer closely replicate the consistency of a real patient. RESULTS: To date, no adequate artificial pelvic models have been available for rectal dissection. Cadaveric models are expensive, and virtual reality trainers, although offering an attractive alternative for some procedures, currently are not available for complex robotic tasks such as rectal dissection. One major advantage of this trainer is that it allows for the surgeon to develop proficiency in both the areas of robotic setup and console without the assistance of a second surgeon. CONCLUSIONS: The trainer described in this report provides an accurate simulation of true robotic rectal dissection. Its portability makes it easy to use at various hospitals. As robotic surgery becomes more common, this training tool has the potential to help surgeons quickly build the skills necessary for the successful use of robotic surgery in the area of rectal dissection.