Reversal of left-sided colostomy utilizing single-port laparoscopy a multicenter European audit and overview of the literature.

BACKGROUND: Stoma reversal surgery can result in considerable morbidity and even mortality. Feasibility of utilizing single-port laparoscopy through the stoma fenestration have been shown before. Aim of the present observational study is to evaluate multicenter experiences of single-port reversal of left-sided colostomy (SPRLC) throughout Europe and to provide an overview of available literature on this topic. METHODS: All patients undergoing SPRLC in four different teaching hospitals throughout Europe are included. Primary outcome was 30-day postoperative complication rate. Secondary outcomes were postoperative length of stay (LOS), single-port success rate and conversion rates. Appraisal of the available literature in PubMed was performed. RESULTS: Of 156 SPRLC procedures, 98.7% of them were technically successful and 71.8% were without postoperative complications. No postoperative mortality was encountered. Superficial site infection occurred in 14.7%, anastomotic leakage in 3.9% and major complications in 8.3%. Median LOS was 4.0 days (1-69), single-port success rate was 64.7%, 12.8% and 21.2% (33/154) were converted to an open and multiport laparoscopic procedure, respectively. Literature shows equally favorable results in 131 patients divided over 5 cohorts with morbidity ranging from 0 to 30.4% and mortality from 0 to 2.2% and median LOS of 4-8 days. CONCLUSION: This study confirms the safety, feasibility and favorable results of the use of single-port approach in the reversal of left-sided colostomy in different centers in Europe with laparoscopic experienced colorectal surgeons. The available literature on this topic support and show equally favorable results using single-port laparoscopy for left-sided colostomy reversal surgery.

Implementation of an easy in-hospital educational stoma pathway results in decrease of home nursing care services after discharge.

AIM: New stoma patients often rely heavily on the assistance of the ward nursing staff during the hospital stay and on the availability of home nursing care services (HNCS) after discharge. An easily executable 4-day in-hospital educational stoma pathway was developed and implemented. The aim was to increase their level of independence (LOI) in order to reduce the need for HNCS after discharge. METHOD: All new stoma patients on the gastrointestinal surgery ward, physically and psychologically capable of performing independent stoma care (SC), were enrolled in this pathway. They were compared to a retrospective control group of new stoma patients before the onset of the stoma pathway. The primary outcome is the need and frequency of HNCS for SC at the moment of discharge. Secondary outcome is the LOI in SC at discharge. RESULTS: A total of 145 patients [m:f = 102:43, median age 67 (range 27-90) years] were included in the present study. Patients requiring daily HNCS for SC decreased from 80% to 50%, P < 0.001; patients discharged without HNCS for SC increased from 5% to 27%. Patients' independence in SC at discharge increased from 8% to 68%, P < 0.001. CONCLUSION: This study shows that a clinical 4-day in-hospital educational stoma pathway is feasible and effective in increasing the LOI in SC of new stoma patients and significantly reducing their need for HNCS. Cost-benefit analysis and applicability of this pathway in multicentre settings are currently being investigated.

Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery.

AIM: Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ-preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS. METHOD: Data were retrieved from the prospective database of the Elisabeth-TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively. RESULTS: From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90-day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1- and 5-year disease-free survival of 85% compared with 97.5% for the pTME group (P = 0.062). CONCLUSION: Completion TME surgery after TAMIS is not associated with increased peri- or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease-free and overall survival when compared with patients undergoing pTME.

Implementation of laser ablation of fistula tract (LAFT) for perianal fistulas: do the results warrant continued application of this technique?

BACKGROUND: Laser Ablation of Fistula Tract (LAFT) is a novel technique for the treatment of perianal fistulas. Initial reports have shown moderate-to-good results. The aim of this study was to evaluate this implementation and the effectiveness of this technique. Patients were offered LAFT as a treatment option for their perianal fistulas at the outpatient clinic between November 2016 and April 2018. Inclusion criteria were intersphincteric and transsphincteric fistula of cryptoglandular origin [10]. Exclusion criteria were supra- or extrasphincteric fistula, Crohn's disease, presence of undrained collections or side tracts and malignancy-related fistula. The primary outcome was fistula healing rate, the main secondary outcome incidence of postoperative fecal incontinence. Healing and postoperative FISI were evaluated at our outpatient clinic during follow-up at 6 and 12 weeks. A questionnaire was sent to all patients to evaluate the long-term postoperative FISI and patient satisfaction after 3 months. RESULTS: Between November 2016 and April 2018, 20 patients [m:f = 4:16, median age 45 (27-78) years] underwent LAFT. Median follow-up was 10 months (IQR 7.3 months). A draining seton was placed in 15 (75%) of all patients with a median time of 12 weeks (IQR 14 weeks) prior to LAFT. Five intersphincteric and 13 transsphincteric fistulas were treated. Overall healing rate was 20% (4/20). The median postoperative fecal incontinence severity index (FISI) score was 0 (range 0-38); however, we found a change in continence in 39% of the patients. CONCLUSIONS: LAFT has now been discontinued as a treatment of cryptoglandular perianal fistulas in our centre, because of its disappointing results. Further detailed research seems to be warranted to investigate its exact indication and limitations.

The effect of proctoring on the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms.

BACKGROUND: The current method of choice for local resection of benign and selected malignant rectal tumors is transanal endoscopic microsurgery. Transanal minimally invasive surgery (TAMIS) yields similar oncological results and better patient reported outcomes when compared to transanal endoscopic micro surgery. However, due to the technical complexity of TAMIS, a significant learning curve has been suggested. Data on the surgical learning curve are limited. The aim of our study was to investigate surgeon specific learning curves for TAMIS procedures for the local excision of selected rectal tumors, and analyze the effects of proctoring on operating time and outcome. METHODS: The current study was prospective of all TAMIS procedures performed by two surgeons from October 2010 to November 2017. Margin positivity, specimen fragmentation, adverse events and operative time were evaluated with a cumulative sum analysis to determine the number of procedures required to reach proficiency. Cumulative sum (CUSUM) analysis was used to determine trends in changes over time. RESULTS: The earliest adopter, surgeon A, performed 103 procedures, was not proctored and developed the standardized institutional program. Surgeon B, performed 26 cases, had the benefit of a proctorship and availability of a standardized program. The CUSUM curve for operative time showed a change after 36 cases for surgeon A and after 10 cases for surgeon B. For margin positivity proficiency was reached after 31 and 6 cases for surgeon A and B, respectively. The complications curve for surgeon A showed a three-phase learning curve with a decrease after the 26th case whereas surgeon B only had one (3.8%) complication in the learning phase with no change point in the CUSUM curve. Comparing pre- and post-proficiency periods there was a decrease in operating time for both surgeon A (84.4 ± 47.3 to 55.9 ± 30.1 min) and surgeon B (90.6 ± 64.to 53 ± 26.5 min; p < 0.001). Overall margin positivity rates decreased non significantly from 21.7 to 4.8% (p = 0.23). Complications were higher in the pre-proficiency period (21.7% vs. 13.0%; p = 0.02). Surgeon A had significantly more postoperative complications in pre-proficiency phase when compared to surgeon B (25% vs. none, p < 0.001), in the post-proficiency phase there was no statistically significant difference between both surgeons (p = 0.08). CONCLUSIONS: Our results suggest that to reach satisfactory results for TAMIS, 18-31 procedures are required. Standardized institutional operative protocols together with proficient proctorship may contribute to a shorter learning curve with fewer cases (6-10) required to reach proficiency.

Transanal minimally invasive surgery for rectal polyps and selected malignant tumors: caution concerning intermediate-term functional results.

PURPOSE: Transanal minimally invasive surgery (TAMIS) is gaining worldwide popularity as an alternative for the transanal endoscopic microsurgery (TEMS) method for the local excision of rectal polyps and selected neoplasms. Data on patient reported outcomes regarding short-term follow-up are scarce; data on functional outcomes for long-term follow-up is non-existent. METHODS: We used the fecal incontinence severity index (FISI) to prospectively assess the fecal continence on the intermediate-term follow-up after TAMIS. The primary outcome measure is postoperative fecal continence. Secondary outcome measures are as follows: perioperative and intermediate-term morbidity. RESULTS: Forty-two patients (m = 21:f = 21), median age 68.5 (range 34-94) years, were included in the analysis. In four patients (9.5%), postoperative complications occurred. The median follow-up was 36 months (range 24-48). Preoperative mean FISI score was 8.3 points. One year after TAMIS, mean FISI score was 5.4 points (p = 0.501). After 3 years of follow-up, mean FISI score was 10.1 points (p = 0.01). Fecal continence improved in 11 patients (26%). Continence decreased in 20 patients (47.6%) (mean FISI score 15.2 points, [range 3-31]). CONCLUSIONS: This study found that the incidence of impaired fecal continence after TAMIS is substantial; however, the clinical significance of this deterioration seems minor. The present data is helpful in acquiring informed consent and emphasizes the need of proper patient information. Functional results seem to be comparable to results after TEMS. Furthermore, we confirmed TAMIS is safe and associated with low morbidity.