Inferior load generated by preloaded versus manually loaded haemorrhoid banding devices: the effect of 'creep relaxation'.

BACKGROUND: The efficacy of rubber band ligation of haemorrhoids relies on the load generated on haemorrhoidal tissue by bands as they return to their preformed shape after being deployed. 'Preloaded' haemorrhoid banding devices are widely available, but the effect of the resultant prolonged stretch on bands while stored in this manner has never been examined by comparing these to manually loaded devices, which are stretch immediately prior to being deployed. A difference could have clinical relevance, potentially resulting in a higher rate of clinical failure. The present study aimed to investigate any difference in load generated by preloaded versus manually loaded devices. METHODS: A preloaded and a manually loaded device were selected for comparison. Each type was measured on a testing rig. The device type, load generated by each band and the time to expiry were recorded. RESULTS: A total of 137 haemorrhoid bands were tested: 66 preloaded and 71 manually loaded. There was a statistically significant overall reduction in load generated by preloaded versus manually loaded devices (284.0 versus 272.1 g, mean difference -11.9 g, 95% confidence interval -17.5 to -6.3 g, P = 0.0001). Adjusted for time, the load generated by preloaded bands fell 3.7 g (95% confidence interval 2.7-4.8, P < 0.001) for each month closer to the expiry date. CONCLUSIONS: The load generated by haemorrhoid bands from preloaded devices is lower and deteriorates significantly towards their expiry date compared with bands from manually loaded devices. This is mostly likely due to their storage in a stretched state. This should be considered by clinicians when using haemorrhoid banding devices.

High efficacy and patient satisfaction with a nurse-led colorectal cancer surveillance programme with 10-year follow-up.

BACKGROUND: Surveillance after colorectal cancer resection remains contentious, and faces several contemporary issues. Patient-centred care, intensive surveillance programmes and patient complexity increase the burden of surveillance on consultant-led clinics. Recent years have seen reshaping of nursing roles to meet healthcare demand. Nurse-led follow-up after colorectal cancer has been piloted, but not validated. We report outcomes from a nurse-led colorectal cancer surveillance clinic functioning in our institution since 2008, the longest term follow-up in the published literature. METHODS: Included patients were surveilled through the clinic from 2008 to 2018 by credentialled nurses who performed history, examination and investigations as per the local protocol. Demographic, tumour-related, outcome-related and patient satisfaction data were extracted from a prospectively maintained database. Primary outcomes were compliance with surveillance protocol and patient satisfaction. RESULTS: A total of 138 patients were included in the analysis. Mean time in surveillance was 25.4 months. Surveillance investigation protocol compliance was 97.4% overall. Five recurrences (3.6%) were detected during surveillance. In patients who developed recurrence, protocol compliance was 100%, and no clinical features of recurrence were newly found when patients were reviewed by a consultant surgeon. All recurrences during surveillance were detected by nursing staff. Response rate to the patient satisfaction survey was 90%. 96.3% of patients reported receiving adequate explanation regarding cancer surveillance and nurse-led care. 90.7% of patients rated the clinic as 'excellent' and 9.3% as 'good'. CONCLUSION: Our results show a high level of efficacy and patient satisfaction associated with a nurse-led colorectal cancer surveillance clinic over a prolonged time period, the longest in the published literature.

Hybrid Transvaginal NOTES and Mini-Laparoscopic Colectomy: Benefit Through Synergy.

BACKGROUND AND OBJECTIVES: Hybrid-natural orifice surgery combines the advantages of traditional transabdominal laparoscopic surgery, while limiting surgical trauma to the abdominal wall. Among various routes of intra-abdominal access, the transvaginal method is most appealing because of its utility and proven safety. We describe a series of 4 colonic resections performed with this approach, combined with minilaparoscopy and needlescopic approaches, and discuss the technical aspects, efficacy, and applicability of this technique. METHODS: Three patients were selected to undergo hybrid transvaginal natural-orifice right hemicolectomy. A fourth patient, who underwent a segmental resection of a splenic flexure carcinoma, was included. Transvaginal port access was obtained via posterior colpotomy, and was used for dissection, vascular ligation, bowel division, and anastomosis. We used a combination of standard laparoscopic, minilaparoscopic, and needlescopic instruments transabdominally, focusing on reduced size and number of access points. RESULTS: Duration of laparoscopy, oncologic outcomes and rate of operative morbidity were comparable to the published literature. Early return of gastrointestinal function and low analgesic requirements was observed in all patients. No morbidity related to transvaginal access was observed and the procedure was performed without difficulty in all cases. CONCLUSION: Colonic resection performed by hybrid natural-orifice technique offers several advantages over purely transabdominal laparoscopic procedures. Transvaginal access is easy to perform and offers excellent safety, efficacy, and versatility, especially for right hemicolectomy. Techniques to reduce abdominal wall surgical trauma, such as minilaparoscopy and needlescopic graspers, can be combined effectively in colonic resections, and may act synergistically to reduce postoperative pain and improve outcomes.