Robotic ileocolic resection with intracorporeal anastomosis for Crohn's disease.

The robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation. We aim to share our institutional experience with robotic ileocolic resection for Crohn's disease (CD) and compare it to a laparoscopic cohort. We identified patients who underwent ileocolic resection for CD with a purely robotic (R) or laparoscopic (L) approach between February 2015 and 2018. Chart review was performed and preoperative, intraoperative, and postoperative data was collected. A total of 47 patients with a mean age of 35.2 years old were identified and 61% were female. Seventy percent [n = 33, (23 females, 69.6%)] of the cases were performed robotically and 30% of the cases [n = 14, (6 females, 42.8%)] were performed laparoscopically. The groups were well matched for age, gender, BMI as well as disease related factors (CD duration; clinical classification and location), perioperative immunosuppression, and surgical history. Time to bowel function was shorter by about 1 day in the robotic group (R: 1.9 ± 0.88 days vs. L: 2.7 ± 0.8 days, p = 0.003). Mean operative time was longer in the robotic group by 51 min and this difference was significant (p = 0.03), however 30.3% of patients underwent ureteral stent placement, which can account for added time in robotic cases. There were less conversions in the robotic group [R: 1(4.3%) vs. L: 1(7%)], but this was not significant. There were no intraoperative complications in either group. Complication (L: 21.4% vs. R: 15.1%, p = 0.605) and reoperation rates (L: 0% vs. R: 3.03%, p = 0.429) were similar. Robotic ileocolic resection for Crohn's disease is as safe and feasible as the laparoscopic approach. This was accomplished with no leaks, major morbidity or mortality and comparable length of stay, with 1 day shorter return of bowel function, and with a lower overall complication rate. The robotic approach offers advantages in Crohn's disease which should be studied further in prospective studies.

The Financial and Clinical Impact of an Electronic Health Record Integrated Pathway in Elective Colon Surgery.

BACKGROUND: Enhanced Recovery after Surgery (ERAS) pathways have been shown to reduce length of stay, but there have been limited evaluations of novel electronic health record (EHR)-based pathways. Compliance with ERAS in real-world settings has been problematic. OBJECTIVE: This article evaluates a novel ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery. METHODS: We performed a retrospective cohort study of surgical patients age ≥ 18 years hospitalized from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing other elective procedures. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay and 30-day readmissions. RESULTS: We included 823 (470 and 353 in the pre- and postintervention, respectively) colon surgery patients and 3,415 (1,819 and 1,596 in the pre- and postintervention) surgical control patients in the study. Among the colon surgery cohort, there was statistically significant (p = 0.040) decrease in costs of 1.28% (95% confidence interval [CI] 0.06-2.48%) per surgical encounter per month over the 18-month postintervention period, amounting to a total savings of $2,730 per patient at the 1-year postintervention period. The surgical control group had a nonsignificant (p = 0.231) decrease in monthly costs of 0.57% (95% CI 1.51 to - 0.37%) postintervention. For the 30-day readmission rates, there were no statistically significant changes in either cohort. CONCLUSION: Our study is the first to report on the reduced costs after implementation of a novel sophisticated E-Pathway for ERAS. E-Pathways can be a powerful vehicle to support ERAS adoption.

Robotic transanal minimally invasive rectal mucosa harvest.

INTRODUCTION: Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. We demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. METHODS: Six patients (ages 28-60) presenting with urethral stricture and one vaginal stricture underwent robotic rectal mucosal harvest. The procedure, which was first studied on an inanimate bovine colon model, was performed under general anesthesia in lithotomy position using the GelPOINTTM Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty. RESULTS: There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months. CONCLUSIONS: To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

Association of dietary fibre intake and gut microbiota in adults.

Increasing evidence indicates that gut microbiota may influence colorectal cancer risk. Diet, particularly fibre intake, may modify gut microbiota composition, which may affect cancer risk. We investigated the relationship between dietary fibre intake and gut microbiota in adults. Using 16S rRNA gene sequencing, we assessed gut microbiota in faecal samples from 151 adults in two independent study populations: National Cancer Institute (NCI), n 75, and New York University (NYU), n 76. We calculated energy-adjusted fibre intake based on FFQ. For each study population with adjustment for age, sex, race, BMI and smoking, we evaluated the relationship between fibre intake and gut microbiota community composition and taxon abundance. Total fibre intake was significantly associated with overall microbial community composition in NYU (P=0·008) but not in NCI (P=0·81). In a meta-analysis of both study populations, higher fibre intake tended to be associated with genera of class Clostridia, including higher abundance of SMB53 (fold change (FC)=1·04, P=0·04), Lachnospira (FC=1·03, P=0·05) and Faecalibacterium (FC=1·03, P=0·06), and lower abundance of Actinomyces (FC=0·95, P=0·002), Odoribacter (FC=0·95, P=0·03) and Oscillospira (FC=0·96, P=0·06). A species-level meta-analysis showed that higher fibre intake was marginally associated with greater abundance of Faecalibacterium prausnitzii (FC=1·03, P=0·07) and lower abundance of Eubacterium dolichum (FC=0·96, P=0·04) and Bacteroides uniformis (FC=0·97, P=0·05). Thus, dietary fibre intake may impact gut microbiota composition, particularly class Clostridia, and may favour putatively beneficial bacteria such as F. prausnitzii. These findings warrant further understanding of diet-microbiota relationships for future development of colorectal cancer prevention strategies.

Three-year cost-effectiveness model for non-animal stabilized hyaluronic acid and dextranomer copolymer compared with sacral nerve stimulation after conservative therapy for the management of fecal incontinence.

BACKGROUND: Two new therapies for fecal incontinence (FI) are now available: non-animal stabilized hyaluronic acid and dextranomer copolymer (NASHA/Dx) and sacral nerve stimulation (SNS). PURPOSE: This study aimed to determine the cost-effectiveness of NASHA/Dx compared with SNS and conservative therapy (CT) for the treatment of FI after CT failure. METHODS: Decision tree models with Markov subbranches were developed to compare all direct costs and outcomes during a 3-year period from the viewpoint of the US third-party payer. Costs (in 2013 US dollars) of devices, medical and surgical care, and hospitalization were included. Outcomes included quality-adjusted life-years (QALYs) and incontinence-free days (IFDs). Both costs and outcomes were discounted at an annual rate of 3%. The incremental cost-effectiveness ratio was calculated for each outcome. One-way and probabilistic sensitivity analyses were performed to examine robustness of results and model stability. A budget impact analysis was also undertaken to estimate the potential cost and savings of NASHA/Dx for a payer with 1,000,000 covered lives. RESULTS: For the 3-year cost-effectiveness models, the expected cost was $9053 for CT, $14,962 for NASHA/Dx, and $33,201 for SNS. The numbers of QALYs were 1.769, 1.929, and 2.004, respectively. The numbers of IFDs were 128.8, 267.6, and 514.8, respectively. The incremental cost-effectiveness ratios per additional IFD gained were $42.60 for NASHA/Dx vs CT, $73.76 for SNS vs NASHA/Dx, and $62.55 for SNS vs CT. The incremental costs per QALY gained were $37,036 for NASHA/Dx vs CT, $244,509 for SNS vs NASHA/Dx, and $103,066 for SNS vs CT. The budget impact analysis evaluated the financial effect on the health care system of the use of NASHA/Dx and SNS. For the scenarios evaluated, when all of the patients receive NASHA/Dx, the net annual effect to the health care payer budget ranged from $571,455 to $2,857,275. When all of the patients receive SNS, the net annual effect to the health care payer budget ranged from $1,959,323 to $9,796,613. CONCLUSION: Both NASHA/Dx and SNS have produced significant improvements in FI symptoms for affected patients. NASHA/Dx is a cost-effective and more efficient use of resources for the treatment of FI when compared with SNS. The budget impact analysis suggests that although reimbursement for NASHA/Dx treatment initially adds costs to the health care system, it is significantly less expensive than SNS for patients who are candidates for either treatment.

Endoanal ultrasound in the staging and management of squamous-cell carcinoma of the anal canal: potential implications of a new ultrasound staging system.

PURPOSE: This study was performed to determine whether endoanal ultrasound could be used to accurately stage patients with squamous-cell carcinoma of the anal canal and to determine the response of these tumors to multimodality therapy. METHODS: Thirteen consecutive patients with biopsy-proven squamous-cell carcinoma of the anal canal between 1996 and 1999 were included in the study. All patients underwent a pretreatment staging endoanal ultrasound with a B&K 3535 ultrasound machine using the 1850 rotating 360 degrees probe with a 10-MHz transducer. Tumors were staged using our own modification of a 1984 TNM staging system. For our study, a uT1 tumor was confined to the submucosa; a uT2a lesion invaded only the internal anal sphincter; a uT2b lesion penetrated into the external anal sphincter; a uT3 lesion invaded through the sphincter complex into the perianal tissues; and a uT4 lesion invaded adjacent structures. After the initial study, patients decided on a course of treatment, either primary surgery or chemoradiation. For patients choosing chemoradiation, a clinical examination with biopsies and a repeat endoanal ultrasound was performed after completion of therapy. Findings on physical examination and biopsy results were compared with the follow-up endoanal ultrasound. For those choosing surgery, the pathology specimen from the abdominoperineal resection was reviewed and compared with the initial endoanal ultrasound interpretation to determine the accuracy of endoanal ultrasound staging. RESULTS: One patient died of complications from acquired immunodeficiency syndrome before undergoing definitive treatment for his anal cancer. Of the remaining 12 patients who comprised the study, the endoscopic staging was as follows: 1 uT1, 5 uT2a, 3 uT2b, 2 uT3, and 1 uT4. Five of the 12 patients selected surgery as the primary treatment modality for their disease. The other seven patients underwent a full course of chemoradiation. In all five patients who had an abdominoperineal resection, the surgical staging correlated with the endoanal ultrasound staging (2 T2a tumors and 3 T2b tumors). In the remaining seven patients, six to eight weeks after completion of therapy, there was no evidence of residual tumor by clinical examination and biopsies. In one of the seven patients, no abnormalities were detected on endoanal ultrasound, and it was interpreted as normal with no evidence of disease. In the remaining six patients, endoanal ultrasound revealed abnormalities that were judged to represent radiation-induced changes rather than residual disease. A repeat endoanal ultrasound was done in these patients two to four months after the biopsies. Complete resolution of the postradiation changes occurred in all patients, and the scans were interpreted as showing no evidence of disease. CONCLUSIONS: Endoanal ultrasound can accurately determine the depth of penetration of squamous-cell carcinoma into the sphincter complex and can be used to gauge accurately the response of these tumors to chemoradiation therapy. Our newly proposed ultrasound staging system may be more useful in choosing treatment options; future studies should be aimed at using endoanal ultrasound in identifying early lesions that may be amenable to less aggressive therapy as well as determining the utility of ultrasound in the surveillance of patients after successful treatment of their initial tumors.