Mesenteric-based surgery for Crohn's disease: evidence and perspectives.

Postoperative anastomotic recurrence of Crohn's disease is challenging and can lead to symptom recurrence and further surgery. The mesenteric pole of the intestine is the initial site of macroscopic anastomotic recurrence, and the mesentery may play an important role in recurrence after surgical resection. Therefore, "mesenteric-based surgery" has gained increasing attention by clinicians. However, the role of mesentery in the postoperative recurrence remains controversial. This review will examine mesenteric changes in Crohn's disease, proposed roles for mesentery in disease progression, and the potential for mesenteric-based surgery in the surgical management of Crohn disease.

Laparoscopic versus open appendicectomy performed by adult general surgeons in pre-teenage years children: a single-centre experience.

INTRODUCTION: The utilisation of laparoscopic appendicectomy (LA) in children remains contentious despite the well-recognised advantages of laparoscopic surgery. The purpose of this study was to compare intraoperative and postoperative outcomes in LA and open appendicectomy (OA) when performed by adult general surgeons outside specialist paediatric practice in younger children. METHODS: A retrospective review of all patients under the age of 13 who underwent LA for suspected appendicitis over a two-year period was conducted. These were case-matched with an equivalent number of patients who underwent OA during the same period. Intraoperative and postoperative outcomes were compared. RESULTS: Fifty-one patients underwent LA during the study period. Patient demographics were statistically equivalent with the OA cohort. A statistically significant longer median operating time (58 vs 49min) was noted in the LA group, but intraoperative outcomes were otherwise comparable. LA, when compared with OA, was associated with a significant improvement in postoperative length of stay (2 vs 3 days, p < 0.001), postoperative complication rate (0% vs 6%, p = 0.01), negative appendicectomy rate (3.9% vs 17.6%, p < 0.001) and 30-day readmission rate (0% vs 5.9%, p = 0.03). No patients in the LA group required conversion to open surgery. CONCLUSION: LA can be safely delivered by adult general surgeons to younger paediatric populations outside the setting of paediatric specialist practice, with statistically significant improvements in postoperative outcomes noted when compared with OA. These findings are of importance in the current healthcare context where adult general surgeons continue to perform the majority of paediatric appendicectomies.

Nurses' perceptions and experiences of robotic assisted surgery (RAS): An integrative review.

AIM: To identify and review published literature on the perceptions and experience of nurses working with RAS. BACKGROUND: Robotic assisted surgery (RAS) is rapidly becoming accepted as the elite modality for surgery since its introduction in the 1980 s, more recently there has been a rising trend of use with several specialities operating using this technology. The role of nurses in perioperative care has been described as maintaining the momentum of the patient's journey. Patients undergoing RAS require nursing care throughout their journey, therefore knowledge of nurses' experiences and perceptions of RAS is important to identifying nurse education and development needs. DESIGN: Integrative literature review DATABASE SOURCES: Databases searched for peer reviewed studies included CINAHL, Academic Search Complete, EMBASE, Scopus, ADA Psycinfo, Medline. REVIEW METHODS: A comprehensive database search was conducted following PRISMA guidelines. Six databases were searched with 523 screened for eligibility. Ten studies were included in the review seven qualitative and three quantitative. RESULTS: Ten studies were identified, critically appraised and synthesised using thematic analysis. All studies were conducted with nurses in the perioperative environment. Key findings were that nurses education regarding RAS is limited with more emphasis placed on surgeon education and training. There was evidence that nurses experienced a lack of education, training and information as barriers to their role which subsequently raised their stress levels. CONCLUSION: Evidence suggests a clear need for education and training for nurses working with RAS. In addition, nurses working with RAS provide care preoperatively, intraoperatively, postoperatively and post discharge in the community. However, no research has been conducted with nurses outside of the perioperative environment. Further research is required to understand the experiences and perceptions of nurses working with RAS patients in all care settings to identify their education and development needs.

Future Directions.

Recent findings related to the mesentery clarified the organisation of the abdomen at the foundational level. The Mesenteric-based model of abdominal anatomy articlulates a foundation that re-unites scientific and clinical approaches to the abdomen in health and disease. Importantly, recent advances are a reminder that we must always question dogma. The peritoneal-based dogma of conventional anatomy remained unquestioned for too long. With time, the mesenteric-based dogma will also be altered and improved on. Anatomy, and hence surgery, must always be considered as works in progress.

The Development of the Mesenteric Model of Abdominal Anatomy.

Recent advances in mesenteric anatomy have clarified the shape of the mesentery in adulthood. A key finding is the recognition of mesenteric continuity, which extends from the oesophagogastric junction to the mesorectal level. All abdominal digestive organs develop within, or on, the mesentery and in adulthood remain directly connected to the mesentery. Identification of mesenteric continuity has enabled division of the abdomen into two separate compartments. These are the mesenteric domain (upon which the abdominal digestive system is centered) and the non-mesenteric domain, which comprises the urogenital system, musculoskeletal frame, and great vessels. Given this anatomical endpoint differs significantly from conventional descriptions, a reappraisal of mesenteric developmental anatomy was recently performed. The following narrative review summarizes recent advances in abdominal embryology and mesenteric morphogenesis. It also examines the developmental basis for compartmentalizing the abdomen into two separate domains along mesenteric lines.

The Mesentery-Past, Present, and Future.

This article summarizes the events that shaped our current understanding of the mesentery and the abdomen. The story of how this evolved is intriguing at several levels. It speaks to considerable personal commitment on the part of the pioneers involved. It explains how scientific and clinical fields went different directions with respect to anatomy and clinical practice. It demonstrates that it is no longer acceptable to adhere unquestioningly to models of abdominal anatomy and surgery. The article concludes with a brief description of the Mesenteric Model of abdominal anatomy, and of how this now presents an opportunity to unify scientific and clinical approaches to the latter.

The Mesentery in Robot-Assisted Total Mesorectal Excision.

In recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed.

Update on the mesentery: structure, function, and role in disease.

Over the past 5 years, systematic investigation of the mesenteric organ has expanded and shown that the mesentery is the organ in and on which all abdominal digestive organs develop and remain connected to. In turn, this observation has clarified the anatomical foundation of the abdomen and the fundamental order at that level. Findings related to the shape and development of the mesentery have illuminated its function, advancing our understanding of the pathobiology, diagnosis, and treatment of several abdominal and systemic diseases. Inclusion of the mesentery in surgical resections alters the course of benign and malignant diseases. Mesenteric-based scoring systems can enhance the radiological interpretation of abdominal disease. Emerging findings reconcile observations across scientific and clinical fields and have been assimilated into reference curricula and practice guidelines. This Review summarises the developmental, anatomical, and clinical advances made since the mesentery was redesignated as an organ in 2016.

Role of Extended Mesenteric Excision in Postoperative Recurrence of Crohn's Colitis: A Single-Center Study.

INTRODUCTION: The mesentery is involved in Crohn's disease. The impact of the extent of mesenteric resection on postoperative disease progression in Crohn's disease remains unconfirmed. This study aimed to determine the association between resection of the mesentery and postoperative outcomes in patients with Crohn's colitis (CC) undergoing colorectal surgery. METHODS: Patients with CC who underwent colorectal resection between January 2000 and December 2018 were reviewed, and the data were gathered from a prospectively maintained database. Patients were divided into 2 groups according to the extent of mesenteric resection, the extensive mesenteric excision (EME) group and the limited mesenteric excision (LME) group. Outcomes including early postoperative morbidities and surgical recurrence were compared between the 2 groups. RESULTS: Of the 126 patients included, 60 were in the LME group and 66 in the EME group. There was no significant difference between the 2 groups in early postsurgical outcomes except the intraoperative blood loss was increased in the LME group (P = 0.002). Patients in the EME group had a longer postoperative surgical recurrence-free survival time when compared with those in the LME group (P = 0.01). LME was an independent predictor of postoperative surgical recurrence (hazard ratio 2.67, 95% confidence interval 1.04-6.85, P = 0.04). This was further confirmed in the subgroup analysis of patients undergoing colorectal resection and anastomosis (hazard ratio 2.83, 95% confidence interval 1.01-7.96, P = 0.048). DISCUSSION: In patients undergoing surgery for CC, inclusion of the mesentery is associated with similar short-term outcomes and improved long-term outcomes compared with those seen when the mesentery is retained.

Adults with Crohn's disease exhibit elevated gynoid fat and reduced android fat irrespective of disease relapse or remission.

Crohn's disease (CD) is a debilitating inflammatory bowel condition of unknown aetiology that is growing in prevalence globally. Large-scale studies have determined associations between female obesity or low body mass index (BMI) with risk of CD at all ages or 8- < 40 years, respectively. For males, low BMI entering adult life is associated with increased incidence of CD or ulcerative colitis up to 40 years later. Body composition analysis has shown that combinations of lean tissue loss and high visceral fat predict poor CD outcomes. Here, we assessed dietary intake, physical activity and whole or regional body composition of patients with CD relapse or remission. This anthropometric approach found people with CD, irrespective of relapse or remission, differed from a large representative healthy population sample in exhibiting elevated gynoid fat and reduced android fat. CD is associated with mesenteric adipose tissue, or "creeping fat", that envelops affected intestine exclusive of other tissue; that fat is localised to the android region of the body. In this context, CD mesenteric adiposity represents a stark juxtaposition of organ-specific and regional adiposity. Although our study population was relatively small, we suggest tentatively that there is a rationale to refer to Crohn's disease as a fatty intestine condition, akin to fatty liver conditions. We suggest that our data provide early insight into a subject that potentially warrants further investigation across a larger patient cohort.

The development and structure of the mesentery.

The position of abdominal organs, and mechanisms by which these are centrally connected, are currently described in peritoneal terms. As part of the peritoneal model of abdominal anatomy, there are multiple mesenteries. Recent findings point to an alternative model in which digestive organs are connected to a single mesentery. Given that direct evidence of this is currently lacking, we investigated the development and shape of the entire mesentery. Here we confirm that, within the abdomen, there is one mesentery in which all abdominal digestive organs develop and remain connected to. We show that all abdominopelvic organs are organised into two, discrete anatomical domains, the mesenteric and non-mesenteric domain. A similar organisation occurs across a range of animal species. The findings clarify the anatomical foundation of the abdomen; at the foundation level, the abdomen comprises a visceral (i.e. mesenteric) and somatic (i.e. musculoskeletal) frame. The organisation at that level is a fundamental order that explains the positional anatomy of all abdominopelvic organs, vasculature and peritoneum. Collectively, the findings provide a novel start point from which to systemically characterise the abdomen and its contents.

Biomarkers in delirium: A systematic review.

BACKGROUND: Delirium is a common neuropsychiatric disorder associated with prolonged hospital stays, and increased morbidity and mortality. Diagnosis is frequently missed due to varying disease presentation and lack of standardized testing. We examined biomarkers as diagnostic or prognostic indicators of delirium, and provide a rational basis for future studies. METHOD: Systematic review of literature published between Jan 2000 and June 2019. Searches included: PubMed; Web of Science; CINAHL; EMBASE; COCHRANE and Medline. Additional studies were identified by searching bibliographies of eligible articles. RESULTS: 2082 relevant papers were identified from all sources. Seventy-three met the inclusion criteria, all of which were observational. These assessed a range of fourteen biomarkers. All papers included were in the English language. Assessment methods varied between studies, including: DSM criteria; Confusion Assessment Method (CAM) or CAM-Intensive Care Unit (ICU). Delirium severity was measured using the Delirium Rating Scale (DRS). Delirium was secondary to post-operative dysfunction or acute medical conditions. CONCLUSION: Evidence does not currently support the use of any one biomarker. However, certain markers were associated with promising results and may warrant evaluation in future studies. Heterogeneity across study methods may have contributed to inconclusive results, and more clarity may arise from standardization of methods of clinical assessment. Adjusting for comorbidities may improve understanding of the pathophysiology of delirium, in particular the role of confounders such as inflammation, cognitive disorders and surgical trauma. Future research may also benefit from inclusion of other diagnostic modalities such as EEG as well as analysis of genetic or epigenetic factors.

Colonisation of the colonic mucus gel layer with butyrogenic and hydrogenotropic bacteria in health and ulcerative colitis.

Butyrate is the primary energy source for colonocytes and is essential for mucosal integrity and repair. Butyrate deficiency as a result of colonic dysbiosis is a putative factor in ulcerative colitis (UC). Commensal microbes are butyrogenic, while others may inhibit butyrate, through hydrogenotropic activity. The aim of this study was to quantify butyrogenic and hydrogenotropic species and determine their relationship with inflammation within the colonic mucus gel layer (MGL). Mucosal brushings were obtained from 20 healthy controls (HC), 20 patients with active colitis (AC) and 14 with quiescent colitis (QUC). Abundance of each species was determined by RT-PCR. Inflammatory scores were available for each patient. Statistical analyses were performed using Mann-Whitney-U and Kruskall-Wallis tests. Butyrogenic R. hominis was more abundant in health than UC (p < 0.005), prior to normalisation against total bacteria. Hydrogenotropic B. wadsworthia was reduced in AC compared to HC and QUC (p < 0.005). An inverse correlation existed between inflammation and R. hominis (ρ - 0.460, p < 0.005) and B. wadsworthia (ρ - 0.646, p < 0.005). Other hydrogenotropic species did not widely colonise the MGL. These data support a role for butyrogenic bacteria in UC. Butyrate deficiency in UC may be related to reduced microbial production, rather than inhibition by microbial by-products.

Urogenital function following robotic and laparoscopic rectal cancer surgery: meta-analysis.

BACKGROUND: Mixed results are reported on clinical and cancer outcomes in laparoscopic rectal cancer surgery (LRCS) compared with robotic rectal cancer surgery (RRCS). However, more favourable functional outcomes are reported following RRCS. This study compared urinary and sexual function following RRCS and LRCS in male and female patients. METHODS: A systematic review and meta-analysis of urinary and sexual function after RRCS and LRCS was performed following PRISMA and MOOSE guidelines, and registered prospectively with PROSPERO (ID:CRD42020164285). The functional outcome reporting tools most commonly included: the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI). Mean scores and changes in mean scores from baseline were analysed using RevMan version 5.3. RESULTS: Ten studies were included reporting on 1286 patients. Some 672 patients underwent LRCS, of whom 380 (56.5 per cent) were men and 116 (17.3 per cent) were women (gender not specified in 176 patients, 26.2 per cent). A total of 614 patients underwent RRCS, of whom 356 (58.0 per cent) were men and 83 (13.5 per cent) were women (gender not specified in 175 patients, 28.5 per cent). Regarding urinary function in men at 6 months after surgery, IPSS scores were significantly better in the RRCS group than in the LRCS group (mean difference (MD) -1.36, 95 per cent c.i. -2.31 to -0.40; P = 0.005), a trend that persisted at 12 months (MD -1.08, -1.85 to -0.30; P = 0.007). ΔIIEF scores significantly favoured RRCS at 6 months [MD -3.11 (95%CI -5.77, -0.44) P <0.021] and 12 months [MD -2.76 (95%CI -3.63, -1.88) P <0.001] post-operatively. Mixed urinary and sexual function outcomes were reported for women. CONCLUSION: This meta-analysis identified more favourable urinary and erectile function in men who undergo robotic compared with conventional laparoscopic surgery for rectal cancer. Outcomes in women did not identify a consistently more favourable outcome in either group. As robotic rectal cancer surgery may offer more favourable functional outcomes it should be considered and discussed with patients.

Degree of Creeping Fat Assessed by Computed Tomography Enterography is Associated with Intestinal Fibrotic Stricture in Patients with Crohn's Disease: A Potentially Novel Mesenteric Creeping Fat Index.

BACKGROUND AND AIMS: Emerging evidence points to a link between creeping fat and the pathogenesis of Crohn's disease [CD]. Non-invasive assessment of the severity of creeping fat on cross-sectional imaging modality has seldom been investigated. This study aimed to develop and characterize a novel mesenteric creeping fat index [MCFI] based on computed tomography [CT] in CD patients. METHODS: MCFI was developed based on vascular findings on CT in a retrospective cohort [n = 91] and validated in a prospective cohort [n = 30]. The severity of creeping fat was graded based on the extent to which mesenteric fat extended around the intestinal circumference using the vessels in the fat as a marker. The accuracy of MCFI was assessed by comparing it with the degree of creeping fat observed in surgical specimens. The relationship between MCFI and fibrostenosis was characterized by determining if these correlated. The accuracy of MCFI was compared with other radiographic indices [i.e. visceral to subcutaneous fat area ratio and fibrofatty proliferation score]. RESULTS: In the retrospective cohort, MCFI had moderate accuracy in differentiating moderate-severe from mild fibrostenosis (area under the receiver operating characteristic [ROC] curve [AUC] = 0.799; p = 0.000). ROC analysis in the retrospective cohort identified a threshold MCFI of > 3 which accurately differentiated fibrostenosis severity in the prospective cohort [AUC = 0.756; p = 0.018]. An excellent correlation was shown between MCFI and the extent of fat wrapping in specimens in the prospective cohort [r = 0.840, p = 0.000]. Neither visceral to subcutaneous fat area ratio nor fibrofatty proliferation score correlated well with the degree of intestinal fibrosis. CONCLUSIONS: MCFI can accurately characterize the extent of mesenteric fat wrapping in surgical specimens. It may become another non-invasive measure of CD fibrostenosis.

Propensity score-matched analysis comparing laparoscopic to robotic surgery for colorectal cancer shows comparable clinical and oncological outcomes.

Robotic colorectal surgery is gaining popularity. The objective of this study was to compare clinical and cancer outcomes in propensity-score matched cohorts (PSM-1:1) undergoing colorectal cancer (CRC) surgery performed using laparoscopic or robotic surgery in a single institution. A PSM cohort comparison was performed in a tertiary referral cancer and National accredited rectal cancer surgery centre. Patients with CRC undergoing laparoscopic or robotic resection with curative intent from 2016 to 2019 (inclusive) were assessed for inclusion. Matched cohorts were selected using a 1:1 ratio. Statistical analysis was performed using SPSS, version 22. 128 patients were analysed [laparoscopic (n = 64); robotic (n = 64)]. Median age was 64 years (29-84 years). 55% (n = 70) of patients were male, 45% female (n = 58). SSI rates were slightly lower in the robotic group [10.9% (n = 7) v 12.5% (n = 8) p = 0.40]. Anastomotic leak rates were equal in both groups [5.4% (n = 3)]. All but one patient received an R0 resection in each group, median LNY was 14 in the robotic group and 12 in the laparoscopic group (p = 0.004) and no difference in disease recurrence (p = 0.465) or survival (p = 0.886) was observed. Structured introduction of a robotic colorectal programme over a 3-year period has resulted in equivalent outcomes with an established laparoscopic programme for CRC.

Role of circulating fibrocytes in the diagnosis of acute appendicitis.

BACKGROUND: Improved diagnostic biomarkers are required for acute appendicitis. The circulating fibrocyte percentage (CFP) is increased in inflammatory states, but has not been studied in acute appendicitis. This study aimed to determine CFP in acute appendicitis and compare diagnostic accuracy with standard serological biomarkers. METHODS: A prospective cohort study was carried out between June 2015 and February 2016 at University Hospital Limerick. The CFP was determined by dual-staining peripheral venous samples for CD45 and collagen I using fluorescence-activated cell sorting, and correlated with histopathological diagnoses. The accuracy of CFP in determining histological acute appendicitis was characterized and compared with the white cell count, C-reactive protein concentration, neutrophil count, lymphocyte count and neutrophil : lymphocyte ratio. RESULTS: Of 95 adults recruited, 15 were healthy individuals and 80 had suspected appendicitis at presentation. Forty-six of these 80 patients had an appendicectomy, of whom 34 had histologically confirmed appendicitis. The CFP was statistically higher in patients with pathologically proven acute appendicitis than in healthy controls (median 6·1 (i.q.r. 1·6-11·6) versus 2·3 (0·9-3·4) per cent respectively; P = 0·008). The diagnostic accuracy of CFP, as determined using the area under the receiver operating characteristic (ROC) curve, was similar to that of standard biomarkers. In multinomial regression analysis, only raised CFP was retained as an independent prognostic determinant of acute appendicitis (odds ratio 1·57, 95 per cent c.i. 1·05 to 2·33; P = 0·027). CONCLUSION: The CFP is increased in histologically confirmed acute appendicitis and is as accurate as standard serological biomarkers in terms of diagnosis.