Standardised approach to laparoscopic total mesorectal excision for rectal cancer: a prospective multi-centre analysis.

PURPOSE: Two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high-quality surgery are equivalent to those achieved by open technique. We present short- and long-term post-operative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic TME for rectal cancer. We describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. METHODS: Prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon at the minimally invasive colorectal unit in Portsmouth between 2006 and 2014 were analysed along with data acquired between 2010 and 2017 from surgeons at three further international centres. Endpoints were overall and disease-free survival at 5 years, and early post-operative clinical and pathological outcomes. RESULTS: Two hundred sixty-three consecutive patients underwent laparoscopic TME surgery by the principal surgeon. At 5 years, overall survival was 82.9% (Dukes' A = 94.4%; B = 81.6%; C = 73.7%); disease-free survival was 84.0% (Dukes' A = 93.3%; B = 86.8%; C = 72.6%). Post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, major morbidity and 30-day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. CONCLUSION: Laparoscopic TME produces excellent long-term survival outcomes for patients with rectal cancer. A standardised approach has the potential to improve outcomes by setting benchmarks for surgical quality, and providing a step-by-step method for surgical training.

Emergency stomas; should non-colorectal surgeons be doing it?

AIM: The aim of this study was to compare general and stoma specific short term complications in patients having stoma surgery in either an emergency or elective setting during their index hospital stay. It also compares the complications specific to a stoma carried out by surgeons with or without a specialist interest in colorectal surgery. BACKGROUND: The stoma created in emergency surgery has a high short and long term complication rate. Emergency stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient's quality of life. METHODS: We retrospectively analysed data for all non-urological stomas created over the last three years in our institute. This covered the period from January 2014 to January 2017. The stoma care department kept a full database record of all patients. Besides demography we analysed the type of stoma i.e. colostomy or ileostomy, indications for the stoma, most common operation, length of stay (LOS) and short term complications based on the Clavien-Dindo classification. We also analysed the perioperative stoma related complications within the emergency cohort. RESULTS: A total of 199 patients had new ostomies created during the three-year period. Four patients died during the inpatient stay and were excluded from the analysis. The total number of stomas created in the emergency cohort was 60 and 135 stomas were elective procedures. The male to female ratio was 1:1.01. The average age for the emergency cohort was 6 years older than for the elective cohort. There was a statistically significant difference in length of stay between the two cohorts (T Test P Value =.02). There was a higher number of elective patients discharged in the first week compared to the emergency surgery patients. The rate of grade 3 or 4 complications was higher in the emergency cohort of patients. The rate of grade 3 or 4 complications was also much higher in patients operated by surgeons who did not have a specialist interest in colorectal surgery. The majority of grade 3 complications seen in the emergency surgery cohort and operated on by non-colorectal specialists (NCS) were stoma related, i.e retraction, necrosis and prolapse. CONCLUSION: Emergency surgery procedures are frequently bowel related. Emergency stoma surgery should not be taken as trivial procedure, non-colorectal surgeons should take advice and assistance from specialist colorectal surgeons for bowel related cases, particularly when a stoma is involved.

Impact of the English National Training Programme for laparoscopic colorectal surgery on training opportunities for senior colorectal trainees.

BACKGROUND: There is growing concern that the recently introduced National Training Programme for consultants in laparoscopic colorectal surgery will have a negative impact on the training of senior colorectal trainees by minimizing the opportunities available. This study aimed to determine the impact that local implementation of the National Training Programme has had on the operating experience of senior colorectal trainees. METHODS: A prospective study was conducted at a designated national training center for laparoscopic colorectal surgery based in a large district general hospital in England, United Kingdom. All patients undergoing laparoscopic colorectal surgery in our unit between October 2006-September 2008 and October 2008-September 2010 were included in the study. The study variables included number and type of procedure, patient demographics, American Society of Anesthesiology grade, body mass index, conversion rates, previous abdominal surgery, and median operating time. The main outcome measure was the number of procedures performed by senior colorectal trainees before and after commencement of National Training Programme training in October 2008. RESULTS: A total of 746 laparoscopic colorectal resections were performed. Senior colorectal trainees performed 175 cases before commencement of the National Training Programme and 184 cases afterward. The difference was not significant. National Training Programme consultants performed 126 cases. Data were analyzed using Fisher's exact test and the Mann-Whitney U test. The study groups were found to be well matched. The median operating time was significantly longer after commencement of the National Training Programme. The study was limited in terms of ability to extrapolate results to smaller units wishing to participate in training programs. CONCLUSION: Implementation of the National Training Programme in our hospital has not had a negative impact on the training opportunities for senior colorectal trainees. However, any unit wishing to participate in the National Training Programme must ensure that an adequate operative caseload and extra resources for operative lists are available for training.

Laparoscopic pouch surgery in ulcerative colitis.

Laparoscopic restorative proctocolectomy is a complex procedure with a steep learning curve. It has been proven to be safe and feasible with outcomes comparable to those of open surgery if performed in experienced centers. Published evidence in favor of laparoscopic approach is mainly from small case series and data from randomized controlled trials are currently awaited. This article reviews and analyzes the existing literature on laparoscopic ileoanal pouch surgery in light of the available evidence, demonstrating safety and efficacy of the laparoscopic approach and potential short-term benefits. Technical aspects and future directions in the minimally invasive approach to restorative proctocolectomy are also discussed.

Modular training in laparoscopic colorectal surgery maximizes training opportunities without clinical compromise.

BACKGROUND: Laparoscopic surgery is increasingly proposed as the gold standard technique for colorectal resections and is offered to greater numbers of patients. To meet the rising service demands, more trainees and established consultants need to learn the technique. We sought to establish whether it is feasible and safe to train on a large proportion of patients without adversely affecting clinical outcome or smooth running of clinical service. METHODS: Between September 2006 and July 2008, four senior trainees of the Wessex Specialist Registrar training rotation were involved in training in laparoscopic colorectal surgery. Major colorectal resections were separated into clearly defined modules for training purposes. Right and left hemicolectomies each comprised two modules, and low anterior resection comprised three modules. Prospective data on consecutive patients undergoing laparoscopic colorectal surgery were collected. Data included type of surgery, module of procedure performed by trainee or trainer, body mass index (BMI), conversion rates, median operative time, complications, length of hospital stay, and mortality. RESULTS: During the study period 227 colorectal resections were attempted laparoscopically. Of these, 216 (96%) proved suitable for training and 97% were completed laparoscopically. Some 23% of patients were American Society of Anesthesiologists score (ASA)≥3; 35% had a BMI≥28; 38% had a history of previous laparotomy. Trainees performed 96% (142/148) of right hemicolectomy modules, 99% (154/156) of left hemicolectomy modules, and 67% (128/192) of rectal resection modules. Each trainee was competent to do right and left hemicolectomy at the end of the training period. Four patients (2%) required further surgery for postoperative complications. Of the procedures completed by the trainees, 155/171 (91%) cancer resections were potentially surgically curative, and R0 resections were achieved in 99%. The readmission rate was 10% (22/216) and median length of hospital stay was 4 days. Postoperative mortality was zero. CONCLUSIONS: Using a modular approach it is possible to provide effective training during almost all laparoscopic colorectal resections while achieving good clinical outcomes for the patients.

Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery.

BACKGROUND AND OBJECTIVES: The excellent outcomes reported for laparoscopic colorectal surgery in selected patients could also be potentially advantageous for high risk patients. This prospective study was designed to examine the feasibility and safety of laparoscopic resection in high risk patients with colorectal cancer. METHODS: Between 2006 and 2008 consecutive patients undergoing elective surgery for colorectal cancer were stratified into high and low risk groups. High risk was defined as >or=80 years, American Society of Anesthesiologists >or=3, preoperative radiotherapy, T4 tumor and BMI >or=30. Outcomes included median length of stay, lymph node yield, resection margins, 30-day hospital readmission, postoperative mortality and major postoperative complications requiring reoperation within 30 days of surgery. RESULTS: A total of 424 patients underwent elective laparoscopic (224) and open (200) resections. Overall mortality rate for laparoscopic resection was 1 of 224 (0.4%) versus 4 of 200 (2%) for open resection. Median length of stay was 4 (2-33) versus 10 (1-69) days (P < 0.0001), and rate of complications requiring reoperation was 2 of 224 (0.8%) compared with 10 of 200 (5%) (P = 0.02).Among the 280 (66%) "high risk" patients, 146 had laparoscopic resection (8 conversions; 5%) and 134 had open resections. Median hospital stay was 4 (2-33) days in the laparoscopic group versus 11 (1-69) days in the open group (P < 0.0001). Complications requiring reoperation were 2 of 146 (1.4%) after laparoscopic resection versus 7 of 134 (5.2%) after open resection (P < 0.09). Readmission rate after laparoscopic resection was 12.3% versus 5.2% after open resection (P = 0.06). CONCLUSION: Laparoscopic resection of colorectal cancer can achieve excellent results even in "high risk" patients and is associated with significant reductions in length of stay compared with open resection.

A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study.

CONTEXT: Postoperative enteral nutrition is thought to reduce complications and speed recovery after pancreatic resection. There is little evidence on the best route for delivery of enteral nutrition. Currently we use percutaneous transperitoneal jejunostomy or percutaneous transperitoneal gastrojejunostomy, or the nasojejunal route to deliver enteral nutrition, according to surgeon preference. OBJECTIVE: To compare morbidity, efficiency, and safety of these three routes for enteral nutrition following pancreaticoduodenectomy. PATIENTS: Data were obtained from a prospectively maintained database, for all patients undergoing pancreatic resection between January 2007 and June 2008. One-hundred pancreatic resected patients underwent enteral nutrition: 93 had Whipple's operations and 7 had total pancreatectomies. INTERVENTION: Enteral nutrition was delivered by agreed protocol, starting within 24 h of operation and increasing over 2-3 days to meet full nutritional requirement. RESULTS: Delivery route of enteral nutrition was: percutaneous transperitoneal jejunostomy in 25 (25%), percutaneous transperitoneal gastrojejunostomy in 32 (32%) and nasojejunal in 43 (43%). The incidence of catheter-related complications was higher in percutaneous techniques: 24% in percutaneous transperitoneal jejunostomy and 34% in percutaneous transperitoneal gastrojejunostomy as compared to nasojejunal technique (12%). Median time to complete establishment of oral intake was 14, 14 and 10 days in percutaneous transperitoneal jejunostomy, percutaneous transperitoneal gastrojejunostomy, and nasojejunal groups, respectively. Nasojejunal tubes were removed at median 11 days (mean 11.5 days) compared to 5-6 weeks for percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy. Commonest catheter-related complication in the percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy was blockage (n=6; 10.5%), followed by pain after removal of feeding tube at 5-6 weeks (n=5; 8.8%), whereas in the nasojejunal group it was blockage (n=3; 7.0%), followed by displacement (n=2; 4.7%). Two patients died postoperatively in this cohort, however, there were no catheter-related mortalities. CONCLUSION: Enteral nutrition following pancreatic resection can be delivered in different ways. Nasojejunal feeding was associated with fewest and less serious complications. On current evidence surgeon preference is a reasonable way to decide enteral nutrition but a randomized controlled trial is needed to address this issue.

Feasibility of laparoscopic distal spleno-pancreatectomy following previous necrosectomy. A case report.

CONTEXT: In recent years, laparoscopic approach to distal pancreatectomy has been increasingly favoured following several reports showing reductions in morbidity and hospital stay compared with open surgery. Previous major abdominal surgery is a relative contraindication for most laparoscopic procedures including distal pancreatectomy. CASE REPORT: We present a case of a young woman in whom we attempted and accomplished safely, a laparoscopic distal pancreatectomy despite having had major pancreatic necrosectomy and discuss the feasibility of this approach. CONCLUSION: It is possible to perform complex laparoscopic pancreatic resections safely in centres with special interest and expertise.

Rectal impaction with epoxy resin: a case report.

We describe a unique case of a patient presenting with rectal impaction following self-administration of a liquid used as masonry adhesive for anal sexual gratification. The solidified matter required laparotomy for its removal. Strategies for removing rectal foreign bodies are discussed as well as other consequences of inserting foreign material per rectum.

Colorectal carcinoma in Nepalese young adults: presentation and outcome.

All cases of primary colorectal carcinoma treated at the Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu during a period of 5 years were retrospectively reviewed in order to promote a greater awareness of the potential for colorectal carcinoma in young adults under 40 years of age. Of the total 91 patients, 26 (28.6%) were younger than 40 years, and this group included more female patients than the older age group. All patients were symptomatic (single or multiple symptoms) for an average period of 7.6 months (range 1 week to 2 years) before seeking medical advice. In the younger group, rectum was the most frequent site of tumors (76.9%) which was significantly higher than in older age group (36.9%). Younger patients were more likely to present with stage III or IV disease (92.3% vs 61.5%) than the older age group (p = 0.001). Moreover, the younger patients had a significantly higher incidence of poorly differentiated and mucinous carcinoma (p = 0.000). Potentially curative resection was performed in only 10 younger patients and most of them had a recurring disease at a median of 11 months. Curative colectomy was more common in > or = 40 age group (29.2% vs 15.4%). The overall 2-year survival rate was significantly lower in younger age group than in the older patients (4% vs 55%, p = 0.0003).