Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study.

AIM: An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches. METHODS: Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach. RESULTS: Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13-16%) in 2018 to 22% (95% CI 20-24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3-5%) versus 7% (95% CI 6-8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38-46%) versus 29% (95% CI 26-31%)]. CONCLUSION: Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.

Changes in rectal cancer treatment after the introduction of a national screening program; Increasing use of less invasive strategies within a national cohort.

AIM: Organ preserving treatment strategies and the introduction of a colorectal cancer-screening program have likely influenced the resection rates of rectal cancer. The aim of this study is to assess the influence of these developments on rectal cancer treatment and resection rates in the Netherlands. METHODS: Patients diagnosed with non-metastatic rectal cancer between 2013 and 2018, were selected from the Netherlands Cancer Registry. The distribution of surgical and neo-adjuvant treatment and resection rates were analyzed and compared over time. RESULTS: Between 2013 and 2018 22640 patients were diagnosed with non-metastatic rectal cancer. The incidence of early stage (cT1) disease increased from 141 (4%) in 2013 to 448 (12%) in 2018. The use of neoadjuvant radiotherapy and chemo-radiotherapy dropped from 39% to 21% and 34%-25%, respectively. A decrease in surgical resection rates (including TEM) was observed from 85% to 73%. The proportion of patients who underwent endoscopic resections increased from 3% to 10%. The decrease in surgical resection rates was larger in patients treated with neo-adjuvant chemo-radiotherapy. CONCLUSION: An increase in stage I disease is noted after the introduction of the screening program. Surgical resection rates for rectal cancer have fallen over time. Endoscopic resections due to more early-stage disease probably accounts for a large part of this decline. Furthermore, a watch and wait approach after neo-adjuvant chemo-radiotherapy may play an important role as well.

Surgery for rectal cancer: Differences in resection rates among hospitals in the Netherlands.

AIM: Numerous quality improvement initiatives for rectal cancer surgery have focused on textbook outcome parameters. In these studies, resection rate and patients who did not undergo surgery are not included, but these parameters might help to evaluate the surgical care for rectal cancer. The aim of this study is to assess the variation of non-metastatic rectal cancer resection rates among hospitals and its effect on patient outcomes. METHODS: All patients diagnosed with non-metastatic rectal cancer between 2013 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were categorized in quartiles according to resection rates. A multivariable logistic analysis was performed to determine variation in resection rate between these quartiles using a logistic regression analysis to correct for confounders. The association between resection rates and survival was analyzed using Kaplan-Meier method and Cox-regression analysis. RESULTS: A total of 22,530 patients were included in the analysis. Resection rates varied from 68 to 89% between hospitals. After multivariable analysis, resection rate remained significantly different among the quartiles when correcting for several factors (odds ratio (95%Confidence-interval) 1.71 (1.56-1.88), 2.42 (2.19-2.67), and 4.04 (3.61-4.53) for increasing resection rate quartiles, in reference to the lowest quartile). A higher resection rate was associated with better overall survival, in multivariable analysis this survival benefit could no longer be identified. CONCLUSION: There is a substantial variation in resection rates for rectal cancer among hospitals in the Netherlands with an impact on overall survival. This may be a relevant issue when analyzing the overall quality of rectal cancer care.

Inter-hospital variation in resection rates of colon cancer in the Netherlands: A nationwide study.

INTRODUCTION: Hospital of diagnosis is shown to have an impact on the probability of undergoing a resection in different types of gastrointestinal cancer. The aim of this study was to investigate the inter-hospital variation in resection rates and its impact on survival among patients with non-metastatic colon cancer. METHODS: All patients diagnosed with non-metastatic colon cancer between 2009 and 2014 were selected from the Netherlands Cancer Registry. Multilevel logistic regression was used to examine the variation in resection rates among hospitals. The effect of variation in surgical resection on overall survival was assessed using Cox regression analyses. Relative survival was used as an estimate for disease-specific survival. RESULTS: 38164 patients, treated in 95 different hospitals, were included in the analysis. After adjustments, resection rates varied between hospitals from 88 to 99%. This variation increased among patients older than 75 years, from 79 to 98%. Crude overall 5-year survival was 64%. After adjustment, no significant difference in overall or relative survival between hospitals with higher and lower resection rates was observed. CONCLUSION: Resection rates are important to consider when interpreting hospital outcomes. There is a significant variation in resection rates in patients with non-metastatic colon cancer among hospitals in the Netherlands. This variation increases in the elderly. No significant effect on survival was found. This could imply that undertreatment may play a role as well as that some patients might not benefit from surgery.

Characteristics of different mesh types for abdominal wall repair in an experimental model of peritonitis.

BACKGROUND: The use of synthetic mesh to repair a potentially contaminated incisional hernia may lead to higher failure rates. A biological mesh might be considered, but little is known about long-term results. Both biological and synthetic meshes were investigated in an experimental model of peritonitis to assess their characteristics in vivo. METHODS: Male Wistar rats were randomized into five groups and peritonitis was induced. A mesh was implanted after 24 h. Five meshes were investigated: Permacol™ (cross-linked collagen), Strattice™ (non-cross-linked collagen), XCM Biologic® (non-cross-linked collagen), Omyra® Mesh (condensed polytetrafluoroethylene) and Parietene™ (polypropylene). The rats were killed after either 30, 90 or 180 days. Incorporation and shrinkage of the mesh, adhesion coverage, strength of adhesions and histology were analysed. RESULTS: Of 135 rats randomized, 18 died from peritonitis. Some 180 days after implantation, both XCM Biologic® and Permacol™ had significantly better incorporation than Strattice™ (P = 0·003 and P = 0·009 respectively). Strattice™ had significantly fewer adhesions than XCM Biologic® (P = 0·001) and Permacol™ (P = 0·020). Thirty days after implantation, Permacol™ had significantly stronger adhesions than Strattice™ (P < 0·001). Shrinkage was most prominent in XCM Biologic® , but no significant difference was found compared with the other meshes. Histological analysis revealed marked differences in foreign body response among all meshes. CONCLUSION: This experimental study suggested that XCM Biologic® was superior in terms of incorporation, macroscopic mesh infection, and histological parameters such as collagen deposition and neovascularization. There must be sufficient overlap of mesh during placement, as XCM Biologic® showed a high rate of shrinkage. Surgical relevance The use of synthetic mesh to repair a potentially contaminated incisional hernia is not supported unequivocally, and may lead to a higher failure rate. A biological mesh might be considered as an alternative. There are few long-term studies, as these meshes are expensive and rarely used. This study evaluated the use of biological mesh in a contaminated environment, and investigated whether there is an ideal mesh. A new non-cross-linked biological mesh (XCM Biologic® ) was evaluated in this experiment. The new non-cross-linked biological mesh XCM Biologic® performed best and may be useful in patients with a potentially contaminated incisional hernia.

[Atrio-oesophageal fistula after thoracoscopic treatment of atrial fibrillation]. / Atrio-oesofageale fisteling na thoracoscopische behandeling van atriumfibrilleren.

BACKGROUND: An atrio-oesophageal fistula (AOF) is a rare but severe complication of radiofrequency ablation during video-assisted thoracoscopic pulmonary vein isolation (VATS-PVI). CASE DESCRIPTION: A 68-year-old man presented to the emergency department with reduced general well-being and a fever. Eight weeks prior he had undergone a VATS-PVI. Blood results revealed elevated inflammatory parameters, and blood cultures were positive for Streptococcus anginosus. A CT-scan demonstrated an air configuration in the left atrium. Shortly after this he developed a left-sided hemiparesis. As a cerebral air embolus due to an AOF was suspected, we decided to operate. The defects in the atrium and the oesophagus were closed primarily during open-heart surgery. CONCLUSION: An AOF is a rare complication following a VATS-PVI. Patients often present with non-specific symptoms like a fever. It is important to be alert of this complication after a VATS-PVI and to perform early diagnostic imaging.