Impact of Anastomotic Leakage After Colorectal Cancer Surgery on Quality of Life: A Systematic Review.

BACKGROUND: Colorectal anastomotic leakage remains one of the most frequent and dreaded postoperative complications following colorectal resection. However, limited research has been conducted on the impact of this complication on quality of life of patients undergoing colorectal cancer surgery. OBJECTIVE: The aim of this systematic review was to identify, appraise and synthesize the available evidence regarding quality of life in patients with anastomotic leakage following oncological colorectal resections in order to inform clinical decision-making. DATA SOURCES AND STUDY SELECTION: PubMed, Embase, and the Cochrane library were searched for studies reporting on quality of life using validated questionnaires in patients with anastomotic leakage after oncological colorectal resections. The literature search was performed systematically and according to PRISMA guidelines. OUTCOMES: Outcomes of quality of life questionnaire scores of patients with and without anastomotic leakage were analyzed. RESULTS: Thirteen articles reporting on 4618 individual patients were included, among which 527 patients developed anastomotic leakage. Quality of life was evaluated utilizing ten distinct questionnaires administered at various postoperative time points, ranging from 1 month to 14 years. Quality of life outcomes differed across studies and timepoints, but overall scores were most negatively affected by anastomotic leakage up to 12 months postoperatively. LIMITATIONS: There was a high heterogeneity between the included studies based on used questionnaires and time of assessment. CONCLUSION: The published evidence suggests that anastomotic leakage following oncologic colorectal resection is associated with impaired quality of life, especially within the first postoperative year. The impact of anastomotic leakage on quality of life warrants further evaluation and discussion with patients.

Effects of a perioperative educational pathway on ostomy self-care, level of independence and need for visiting nurse services: a comparative observational cohort study.

AIM: Most new ostomy patients are not able to manage ostomy self-care when they are discharged and rely on visiting nurse services for ostomy care. The aim of this study was to determine if a perioperative ostomy educational pathway increases the level of independence and decreases the need for visiting nurse services in new ostomy patients. METHOD: A prospective longitudinal study was conducted between July 2018 and February 2020. Patients who received a colostomy or ileostomy and were treated on the surgery ward were included. Patients who followed a perioperative ostomy educational pathway were compared to a historical control group. The primary outcome measure was the level of independence in ostomy care and the need for visiting nurse services. RESULTS: After discharge, 67.6% of patients in the intervention group (n = 244) were able to independently perform ostomy care and were therefore not relying on visiting nurse services, compared to 15.2% of the patients in the control group (n = 33). The need for visiting nurse services was higher in patients aged ≥70 years (OR 3.20, P < 0.001), those who did not attend the preoperative practice session (OR 3.02, P = 0.002), those with a history of transient ischaemic attack (OR 10.22, P = 0.045) and those with mild cognitive impairment (OR 28.98, P = 0.002). CONCLUSION: A perioperative ostomy educational pathway effectively increased the level of independence and decreased the need for visiting nurse services in new ostomy patients.

Primary Anastomosis Versus End-Ostomy in Left-Sided Colonic and Proximal Rectal Cancer Surgery in the Elderly Dutch Population: A Propensity Score Matched Analysis.

BACKGROUND: Primary anastomosis (PA) in left-sided colorectal cancer (CRC) surgery in elderly patients is disputed. The aim of our study was to evaluate the differences in postoperative outcomes after left-sided CRC surgery in elderly patients in The Netherlands, comparing patients with PA and those who underwent end-ostomy (EO). METHOD: Patients aged ≥ 75 years with stage I-III left-sided CRC, diagnosed and surgically treated in 2015-2017 were selected from the Netherlands Cancer Registry (n = 3286). Postoperative outcomes, short-term (30-, 60-, and 90-day) mortality and 3-year overall and relative survival were analyzed, stratified by surgical resection with PA versus EO. Propensity score matching (PSM) and multivariable logistic regression analysis were conducted. RESULTS: Patients with higher age, higher American Society of Anesthesiologists classification and higher tumor stage, a perforation, ileus or tumor located in the proximal rectum, and after open or converted surgery were more likely to receive EO. No difference in anastomotic leakage was seen in PA patients with or without defunctioning stoma (6.2% vs. 7.0%, p = 0.680). Postoperative hospital stay was longer (7.0 vs. 6.0 days, p < 0.0001) and more often prolonged (19% vs. 13%, p = 0.03) in EO patients. Sixty-day mortality (2.9% vs. 6.4%, p < 0.0001), 90-day mortality (3.4% vs. 7.7%, p < 0.0001), and crude 3-year survival (81.2% vs. 58.7%, p < 0.0001) were significantly higher in EO patients, remaining significant after multivariable and PSM analysis. CONCLUSION: There are significant differences between elderly patients after left-sided CRC surgery with PA versus EO in terms of postoperative length of stay, short-term survival, 3-year overall survival, and relative survival at disadvantage of EO patients. This information could be important for decision making regarding surgical treatment in the elderly.

Female Representation and Position Based on Facts and Members Views in the European Society of Coloproctology.

BACKGROUND: There is wide variation in gender distribution in colorectal surgery across different European countries. OBJECTIVE: This study aimed to evaluate female representation, implicit bias, and members' perception on female participation and representation at the European Society of Coloproctology 2017 annual scientific meeting. DESIGN: This was a retrospective mixed-methods cross-sectional observational study. SETTINGS: The study was conducted using data from the 2017 European Society of Coloproctology annual scientific meeting program and attendees. MAIN OUTCOME MEASURES: The primary outcome measure was the percentage of female speakers in the formal program and assessment for implicit bias. Secondary outcomes were the percentage of women attending the conference, the percentage of women serving on committees, and the results of the online survey. METHODS: Female representation was retrospectively quantified by role, session type, and topic. Implicit bias was measured classifying the introductions of speakers by moderators as formal (using a professional title) or informal (using name only), then further stratified by gender. An online survey was disseminated and analyzed to investigate the members' perception as a benchmark analysis. RESULTS: Disparities were found between sexes, with fewer women attending the conference (25%), serving as session chairs (8%), speakers (21%), and on committees (10%) compared with men. There were no differences across sexes regarding the formal or informal introduction. The survey among our members showed that significantly fewer women felt equally endorsed within the society compared with men (33% versus 63%; p < 0.001). LIMITATIONS: The retrospective design with data available to be analyzed was limited by the sessions recorded (27/49) and survey respondents (28%). CONCLUSIONS: Female representation within European Society of Coloproctology as chair, speaker, attendee, and committee member was much lower than male representation, both in absolute numbers and relative to membership. Greater awareness of this disparity and inclusiveness are aims of our society. The impact of these initiatives will be determined by reevaluating these metrics at the 2020 annual meeting. See Video Abstract at http://links.lww.com/DCR/B384. REPRESENTACIN Y POSICIN FEMENINA EN LA SOCIEDAD EUROPEA DE COLOPROCTOLOGA BASADA EN LOS HECHOS Y LAS OPINIONES DE SUS MIEMBROS: ANTECEDENTES:Existe una amplia variabilidad en la distribución de géneros en la cirugía colorrectal en los diferentes países de Europa.OBJETIVO:Evaluar la representación femenina, el sesgo implícito y la percepción de los miembros sobre la participación y representación femenina en el 12° Congreso científico anual de la Sociedad Europea de Coloproctología.DESIGN:Este fué un estudio observacional retrospectivo de métodos mixtos transversales.AJUSTES:Los análisis se realizaron utilizando los datos del programa cintífico de la reunión y los datos de los presentes en el Congreso de la ESCP en 2017.MEDIDAS PRINCIPALES DE RESULTADOS:La principal medida en el resultado fue el porcentaje de disertantes femeninas en el programa definitivo y la evaluación del sesgo implícito. Los resultados secundarios fueron el porcentaje de mujeres que asistieron a la conferencia, trabajaron en los comités y los resultados de la encuesta informática.METODOS:La representación femenina se cuantificó retrospectivamente según el rol, tipo de sesión y temas. Se midió el sesgo implícito clasificando las introducciones de los disertantes por parte de los moderadores de manera formal (usando un título profesional) o informal (usando solamente el nombre), y luego fueron estratificadas por género. Se difundió y analizó una encuesta informática para investigar la percepción de los miembros como análisis de referencia.RESULTADOS:Se encontraron disparidades de género, con menos mujeres presentes en la conferencia (25%), obrando como presidentes de sesión (8%), como disertantes (21%) y como miembros de comités (10%) comparadas con los hombres. No hubo diferencia entre sexos con respecto a la introducción formal o informal. La encuesta informática entre los miembros mostró significativamente que menos mujeres se sentían respaldadas igualitariamente dentro de la sociedad comparadas con los hombres (33% frente a 63%, p<0.001).LIMITACIONES:Diseño retrospectivo de datos limitados a las sesiones grabadas (27/49) y a los encuestados (28%) disponibles para el análisis.CONCLUSIONES:La representación femenina dentro de la Sociedad Europea de Coloproctología como presidente, disertante, asistente ó como miembro del comité fué mucho menor que la representación masculina, tanto en números absolutos como en relación con la membresía. Crear una mayor conciencia de esta disparidad de inclusión son prioridad en nuestra sociedad. El impacto de estas iniciativas se determinará re-evaluando estas variables en reuniones futuras. Consulte Video Resumen en http://links.lww.com/DCR/B384.

Effectiveness of the Ileostomy Pathway in Reducing Readmissions for Dehydration: Does It Stand the Test of Time?

BACKGROUND: The ileostomy pathway, introduced in 2011, has proved to be successful in eliminating hospital readmissions for high-output ileostomy or dehydration in the following period of 7 months in a single institution. However, it is unclear whether this short-term success, immediately after the initiation of the program, can be sustainable in the long term. OBJECTIVE: The aim of this study was to assess the efficacy and the durability of the ileostomy pathway in reducing readmissions for dehydration over a longer period of time. DESIGN: This was a retrospective review of the patients who entered into the ileostomy pathway, since its introduction on March 1, 2011, until January 31, 2015. SETTINGS: This study was conducted at a tertiary academic center. PATIENTS: Patients undergoing colorectal surgery with the creation of a new end or loop ileostomy were included. INTERVENTION: The long-term sustainability of the ileostomy pathway was assessed. MAIN OUTCOME MEASURES: The primary end point was readmission within 30 days after discharge for a high-output ileostomy or dehydration. RESULTS: A total of 393 patients (male n = 195, female n = 198, median age 52 (18-87) years) were included: 161 prepathway and 232 on-pathway. Overall 30-day postdischarge readmission rates decreased from 35.4% to 25.9% (p = 0.04). Readmissions due to high output and/or dehydration dropped from 15.5% to 3.9% (p < 0.001). Readmissions due to small-bowel obstructions dropped from 9.9% to 4.3%, (p = 0.03). LIMITATIONS: The possible limitations of the study included a nonrandomized comparison of the patient groups and those patients who were possibly admitted to different institutions. CONCLUSIONS: The present ileostomy pathway decreases readmissions for high-output ileostomy and dehydration in patients with new ileostomies and is durable in the long term. See Video Abstract at http://links.lww.com/DCR/B233. EFICACIA DE VÍA DE ILEOSTOMÍA PARA REDUCIR LOS REINGRESOS POR DESHIDRATACIÓN: ¿RESISTE LA PRUEBA DEL TIEMPO?: La vía de ileostomía, introducida en 2011, ha demostrado ser exitosa en la eliminación de reingresos hospitalarios por ileostomía de alto rendimiento o deshidratación, por un período de 7 meses, en una sola institución. Sin embargo, no se ha aclarado si el éxito es a corto plazo, inmediatamente después del inicio del programa, y de que pueda ser sostenible a largo plazo.El objetivo de este estudio fue evaluar la eficacia y la durabilidad de la vía de ileostomía, para disminuir los reingresos por deshidratación, durante un período de tiempo más largo.Esta fue una revisión retrospectiva de pacientes que ingresaron a la vía de ileostomía, desde su introducción el 1 de marzo de 2011 hasta el 31 de enero de 2015.Este estudio se realizó en un centro académico terciario.Se incluyeron pacientes sometidos a cirugía colorrectal con la creación de una nueva ileostomía de extremo o asa.Evaluar la sostenibilidad de la vía de ileostomía a largo plazo.El punto final primario fue el reingreso dentro de los 30 días posteriores al alta, por una ileostomía de alto gasto o deshidratación.Se incluyeron un total de 393 pacientes (hombres n = 195, mujeres n = 198, edad media 52 [18-87] años), 161 antes de la vía y 232 en la vía. En general, las tasas de reingreso después del alta a 30 días, disminuyeron de 35.4% a 25.9% (p = 0.04). Los reingresos por alto rendimiento y / o deshidratación, disminuyeron del 15.5% al 3.9% (p < 0.001). Los reingresos debidos a obstrucciones del intestino delgado, disminuyeron del 9.9% al 4.3% (p = 0.03).Las posibles limitaciones del estudio incluyeron una comparación no aleatoria de los grupos de pacientes, y de aquellos pacientes que posiblemente fueron admitidos en diferentes instituciones.La vía de ileostomía disminuye los reingresos por ileostomía de alto gasto y deshidratación, en nuevos pacientes con ileostomía, y es duradera a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B233.

Reversal of left-sided colostomy utilizing single-port laparoscopy: single-center consolidation of a new technique.

BACKGROUND: Considerable morbidity (10-14%) and even mortality (4-30%) have been reported after reversal of intestinal continuity following Hartmann's procedure. Feasibility of and advantages in reducing peri- and postoperative morbidity by utilizing single-port techniques through the colostomy site have been suggested before in small case series. The purpose of the present prospective observational study is to evaluate the outcomes of reversal of intestinal continuity using single-port access in a relatively large consecutive cohort. METHODS: All consecutive patients undergoing single-port reversal of left-sided colostomy (SPRLC) between November 2012 and 2018 were included in the present study. Primary outcome was 30-day postoperative complication rate. Secondary outcomes were postoperative length of stay, single-port success rate, and surgical details like duration and conversion rates. RESULTS: Of 85 procedures, 69.4% were without postoperative complications. No postoperative mortality was encountered. Superficial site infection is the most frequent complication and occurred in 22.4%, major complications classified as Clavien-Dindo grade 3 or above in 9.4% and anastomotic leakage in 3.5%. Median length of stay was 3.0 days (1-69), single-port success rate was 64.7%, and 15.3% was converted to an open procedure. CONCLUSION: This study confirms the safety, feasibility, and the advantages of SPRLC. In centers with adequate laparoscopic experienced surgeons, this technique should be considered as a serious and attractive alternative to restore intestinal continuity in patients with left-sided end colostomy, especially in patients after open index surgery. More research must be done in a multicenter setting to evaluate the use and standardization of single-port technique in reversal of intestinal continuity procedures.

Reversal of Hartmann's procedure utilizing single-port laparoscopy: an attractive alternative to laparotomy.

BACKGROUND: Complications after restoration of intestinal continuity (RIC) following Hartmann's procedure occur frequently and are often serious. These complications result in a reported morbidity of 4-30 % and a reported mortality of 10-14 %. Reducing the amount of surgical trauma accompanying abdominal access seems an attractive tool to reduce perioperative morbidity. This possibility is offered by single-port Hartmann's reversal (SPHR) through the colostomy site. METHODS: The purpose of the present prospective study was to compare outcome of SPHR to a retrospectively collected historical control group of conventional open Hartmann's reversal (OHR). All patients undergoing RIC between January 1, 2009, and January 1, 2014, were included in the present study. Operation time, morbidity and hospital stay were assessed. Postoperative surgical results of SPHR and OHR were the main outcome of the study. RESULTS: During the study period, 41 patients (M/F = 23:18; median age 58 (26-85) years) were included in the present study. Sixteen patients underwent OHR; 25 patients underwent SPHR. No mortality was observed in the present series. Median operation time was similar between groups [184 (29-377) vs. 153.5 (73-332) min]. Hospital stay was significantly shorter in the SPHR group [16 (4-74) vs. 4 (1-34) days, p < 0.05]. The number of complications was significantly lower in the SPHR group (33 vs. 10, p < 0.05); furthermore, significantly less patients had severe complications (Clavien-Dindo III or higher) in the SPHR group (7/33 vs. 1/10). Less wound-related complications occurred in the SPHR group (12 vs. 5, p < 0.05). CONCLUSION: This study confirms recent findings in the literature regarding the safety and feasibility of SPHR. SPHR seems to be an attractive alternative to OHR.

Comparative Quality of Life in Patients Following Transanal Minimally Invasive Surgery and Healthy Control Subjects.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) is considered the successor of transanal endoscopic microsurgery (TEMS). It makes use of more readily available laparoscopic instruments and single-port access platforms with similar perioperative, clinical and oncological outcomes. Little is known about quality of life (QoL) outcomes after the use of TAMIS. The aim of this study was to assess QoL after TAMIS in our patients and compare this with QoL in the healthy Dutch population. METHODS: All patients undergoing TAMIS for selected rectal neoplasms between October 2011 and March 2014 were included in this analysis. Patients were studied for a minimal period of 24 months. QoL outcomes were measured using the Short-Form 36 Health Survey (SF-36) questionnaire; faecal continence was measured using the Faecal Incontinence Severity Index questionnaire. Patient reported outcomes were compared to case-matched healthy Dutch control subjects. We hypothesise that undergoing TAMIS will subsequently result in a decreased quality of life in patients compared to healthy individuals. RESULTS: Thirty-seven patients (m:f = 17:20, median 67 years) were included in the current analysis. In four patients (10.8%), postoperative complications occurred. The median follow-up was 36 (range 21-47) months. Postoperative QoL scores are similar comparable to those reported by Dutch healthy controls. Patients reported a statistically significant better QoL score in the 'bodily pain' domain when compared to the controls (81.8 vs. 74.1 points) (p = 0.01). Significant worse QoL scores for the 'social functioning' domain were reported by patients after TAMIS (84.4 vs. 100 points) (p = 0.03). CONCLUSION: TAMIS seems to be a safe technique with postoperative QoL scores similar to that of healthy case matched controls in 3-year follow-up. There seems to be no association between faecal incontinence and reported QoL. Negative effects of TAMIS on social functioning of patients should not be underestimated and should be discussed during preoperative counselling.

Use of Epidural Analgesia in Sigmoidectomy: Is There Any Advantage in the Era of Minimally Invasive Surgery?

BACKGROUND: There is no consensus as to the effects of epidural analgesia on postoperative outcomes after laparoscopy in the context of the Enhanced Recovery Programs. The aim of this study was to evaluate the effects of epidural analgesia on postoperative outcomes after elective laparoscopic sigmoidectomy. METHODS: The use of epidural analgesia was discontinued in elective laparoscopic sigmoidectomy and substituted by the perioperative administration of systemic lidocaine. Data from patients undergoing elective laparoscopic sigmoidectomy between January 2014 and September 2016 was prospectively analysed. Patients with epidural analgesia were compared with patients without, in analgesics administrated postoperatively, length of stay, day of first defecation and mobilisation, and complication and reoperation rates. RESULTS: A total of 160 patients (male 85; female 75), median age 68 (30-92 years), were included. The groups consisted of 80 patients each. Mean length of stay (5.6 vs. 7.2 days, p = 0.03) and day of first mobilisation (mean 1.2 vs. 1.6 days, p = 0.004) were significantly shorter in the group without epidural analgesia. Reoperation rate (7.5 vs. 2.5%) was not statistically different. Complication rate was significantly lower (12.5 vs. 30%, p = 0.007) in the group without epidural. Day of first defecation was shorter in the epidural group (1.4 vs. 1.7 days, p = 0.04). Mean amount of analgesics administrated was not statistically different between groups, except for metamizole, that was administrated more in the group without epidural. CONCLUSIONS: Epidural analgesia did not offer benefits on postoperative analgesia or outcomes after elective laparoscopic sigmoidectomy, causing longer length of stay, later mobilisation and higher complication rate.

Laparoscopic Fenestration of a Giant Pseudocyst after Totally Extra Peritoneal Inguinal Hernia Repair.

A giant pseudocyst is a rare complication after hernioplasty and is seldom seen. The pathophysiology is unclear; it characteristically does not contain epithelial lining and can be considered giant if the diameter exceeds 10 cm. Pseudocysts are mostly described after incisional hernia repairs and are usually treated with surgical resection. We report a case of a giant pseudocyst three years after totally extra peritoneal inguinal hernia repair. Laparoscopic fenestration without removing the pseudocyst with or without removal of the polypropylene mesh is a safe and effective minimal invasive approach to the treatment of a symptomatic pseudocyst and should also be considered in the approach of other large symptomatic cysts.