Short learning curve in transition from laparoscopic to robotic-assisted rectal cancer surgery: a prospective study from a Finnish Tertiary Referral Centre.

The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien-Dindo III-IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.

Long-term outcomes of patients with acute severe ulcerative colitis treated with cyclosporine rescue therapy.

BACKGROUND AND AIMS: The early outcomes of ulcerative colitis (UC) after rescue therapy with cyclosporine A (CyA) are well known. Published data on the safety of this treatment in perioperative use and data on the long-term prognosis are scarce and are investigated here. METHODS: All UC patients treated with CyA in Tampere University Hospital between 2009 and 2018 were reviewed from patient records. RESULTS: A total of 182 patients were included with the median follow-up of 3.8 (range 0-13) years. Of all patients, 139 (76%) responded to CyA. A quarter of the responders achieved long-term remission and used thiopurines as maintenance therapy at the end of follow-up. Altogether 83 (46%) needed further enhancement of treatment with corticosteroids (Cs) and 57 (31%) with biologicals or small molecules. Of the nonresponders 27 (55%) were treated surgically within admission to index flare. Infliximab was used as a third-line rescue therapy for 16 patients of whom four benefitted. The overall colectomy rate in this series was 45%. When compared to Cs alone CyA did not increase the risk for severe postoperative complications in patients treated for severe treatment-refractory UC. CONCLUSION: In conclusion, despite the good initial response to CyA, a large proportion of patients relapsed during long-term follow-up and the colectomy rates remain high. Other therapy attempts after failure of CyA merely postpone surgery in many. We therefore recommend informing patients about the possibility of surgery prior to the initiation of rescue therapy.

Pouch failures following restorative proctocolectomy in ulcerative colitis.

PURPOSE: Restorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision. METHODS: The number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016. RESULTS: Out of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn's disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn's disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I-II). CONCLUSIONS: Eleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn's disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.

Long-term functional outcome after restorative proctocolectomy: a cross-sectional study.

OBJECTIVE: Restorative proctocolectomy is the procedure of choice in the surgical treatment of ulcerative colitis. Functional outcome is the key result of surgery. The aim of this study was to evaluate the long term-functional outcome after the procedure. MATERIAL AND METHODS: The study comprised 282 ulcerative colitis patients over 18 years of age who underwent restorative proctocolectomy between1985 and 2009. The median follow-up time was 13 years (range 4-28). Functional outcome of the pouch was evaluated by the disease-specific Öresland questionnaire with a score 0-15; 15 being the worst, and score <8 considered well-functioning. RESULTS: The mean functional score was 5.5 (men 5.6, women 5.0). Seventy per cent of the patients had a well-functioning pouch. Those with poor function had had significantly more pouchitis than the patients with well-functioning pouches, 51.0 vs. 25.6% respectively (p = .001). No association was found between functional score and the time since the operation. In multiple regression analysis only the occurrence of pouchitis was associated with poor functional results. CONCLUSIONS: The functional results were good and remained stable in the majority of the patients. Pouchitis seemed to have a negative impact on the functional results. Elderly patients especially need careful planning and counselling before restorative proctocolectomy.

Predictors of quality-of-life after ileal pouch-anal anastomosis in patients with ulcerative colitis.

OBJECTIVES: Predictors of the postoperative quality of life (QoL) following ileal pouch anal anastomosis (IPAA) have not been thoroughly investigated. This study was planned to assess the postoperative QoL following IPAA and to identify its predictors using the 15D instrument. MATERIALS AND METHODS: A retrospective cohort study was conducted on IPAA-operated patients with ulcerative colitis in two Finnish tertiary hospitals during the period 1985-2014 (n = 485). Medical records were examined to collect data on baseline, operative and postoperative characteristics. Patients were surveyed using the 15D-instrument to assess their postoperative QoL. Linear regression analyses and receiver operating characteristic curve were applied to identify the predictors of postoperative QoL. RESULTS AND CONCLUSIONS: Of all patients, 61.5% experienced worse postoperative QoL, with significantly lower QoL level than that of an age and sex-standardized general population in 12 dimensions of the 15D-instrument, with the highest mean difference QoL scores calculated for excretion, sexual activity and sleeping dimensions. Older age and preoperative hypertension were the only significant predictors of lower overall QoL (p = .003 and p = .03, respectively). A preoperative age of ≥35 years was the most valid predictor of lower postoperative QoL (Sensitivity = 62.4% and Specificity = 49.6%, p = .04). In conclusion, postoperative QoL is generally low using the 15D-instrument after IPAA. Worse postoperative QoL is predicted after the age of 35.