Patient experiences of left-sided colorectal resection by robotic, conventional laparoscopic and open approaches: a qualitative study.

BACKGROUND: Robotic surgery (RS) is increasingly employed in colorectal surgical practice, widening the range of surgical techniques offered to patients. We investigated the perceptions of patients with colorectal cancer in relation to RS, open surgery (OS) and conventional laparoscopic surgery (CLS), to identify ideas or assumptions which, in the context of shared surgeon-patient decision-making, may affect the resultant choice of surgical technique. We also investigated salient factors affecting patients' perioperative experience, including those of RS patients, to guide improvements in care and preoperative patient preparation. METHODS: This study was conducted on patients who underwent resection of left-sided colorectal cancer at a large UK teaching hospital from November 2020 to July 2021. Purposive sampling was used to ensure a roughly equal proportion of patients who underwent RS, CLS and OS. The patients included in the study participated in semi-structured interviews six weeks postoperatively. The interview schedule allowed discussion around patients' experience of their surgery and postoperative recovery, and their perceptions of surgical techniques. Interview transcripts were coded manually using inductive thematic analysis, and analyst triangulation was employed to refine coding schemes and ensure reliability of emerging themes. RESULTS: Twenty-seven patients were recruited to the study; RS n = 9 (median age 69 [range 60-80] years); CLS n = 10 (median age 72 [range 32-82] years; OS n = 8 (median age 71 [range 60-75] years). Patients understood the technological benefits of RS but were concerned by a risk of technological failure causing patient harm. OS was understood to be associated with more pain and longer recovery than RS or CLS. Patients perceived CLS to be more technically challenging compared with OS. Less pain and smaller wounds than expected were significant positive factors in the experience of RS and CLS patients specifically. Complications and emotional impact were significant factors in the experience of all groups, for which many patients felt underprepared. CONCLUSIONS: Patients generally have a positive view of RS and technical innovation in surgery. Concerns mostly centred around failure of technology. Many patients felt unprepared for significant factors in their perioperative experience. Surgeons and healthcare providers should be prepared to address patients' perceptions and expectations of colorectal surgery preoperatively.

The use of topical anaesthetic in the banding of internal haemorrhoids: a feasibility study for a randomised control trial.

INTRODUCTION: Rubber band ligation (RBL) is a procedure commonly performed in colorectal clinics for internal haemorrhoids. Overall, 90% of patients experience pain following RBL. We aimed to complete a feasibility randomised control trial assessing the role of topical anaesthetic before RBL of internal haemorrhoids. METHODS: We performed a prospective, single-centre, single blinded, randomised (1:1) control feasibility trial. Patients presenting with symptomatic haemorrhoids suitable for banding were randomised to undergo the procedure with local anaesthetic or without (control). Pain scores and vasovagal symptoms were assessed at 0 minutes, 30 minutes, 4 hours and 72 hours after the procedure. Primary outcome measures were recruitment rate, participant retention rate and patient and surgeon acceptability. Secondary outcome measures were pain scores up to 72 hours, vasovagal episodes, new use of analgesia and adverse outcomes. RESULTS: In total, 35 patients (18 topical anaesthetic, group A; 17 no anaesthetic gel, group B) were recruited. Mean recruitment rate was 11.7 participants per month. Thirty-three (94%) participants remained in the study until completion, with two patients lost to telephone follow-up. The treatment was acceptable for 35 (97%) eligible patients. One patient declined enrolment. The treatment was acceptable to all surgeons (100%). There was a significant difference in median pain scores of -2 (95% CI -4.0 to -1.0, p=0.0006) at the 30-minute time point only. There was no significant difference in vasovagal symptoms (p=0.10) or new analgesia use (p=0.85). CONCLUSION: We have shown that a phase III clinical trial is feasible for assessing the role of topical anaesthetic before RBL of internal haemorrhoids. We have demonstrated excellent patient recruitment and retention as well as patient and surgeon acceptability.

Renal impairment after ileostomy formation: a frequent event with long-term consequences.

AIM: High stoma output and dehydration is common following ileostomy formation. However, the impact of this on renal function, both in the short term and after ileostomy reversal, remains poorly defined. We aimed to assess the independent impact on kidney function of an ileostomy after rectal cancer surgery and subsequent reversibility after ileostomy closure. METHODS: This retrospective single-site cohort study identified patients undergoing rectal cancer resection from 2003 to 2017, with or without a diverting ileostomy. Renal function was calculated preoperatively, before ileostomy closure, and 6 months after ileostomy reversal (or matched times for patients without ileostomy). Demographics, oncological treatments and nephrotoxic drug prescriptions were assessed. Outcome measures were deterioration from baseline renal function and development of moderate/severe chronic kidney disease (CKD ≥ 3). Multivariate analysis was performed to assess independent risk factors for postoperative renal impairment. RESULTS: Five hundred and eighty-three of 1213 patients had an ileostomy. Postoperative renal impairment occurred more frequently in ileostomates (9.5% absolute increase in rate of CKD ≥ 3; P < 0.0001) vs no change in patients without an ileostomy (P = 0.757). Multivariate analysis identified ileostomy formation, age, anastomotic leak and renin-angiotensin system inhibitors as independently associated with postoperative renal decline. Despite stoma closure, ileostomates remained at increased risk of progression to new or worse CKD [74/438 (16.9%)] compared to patients without an ileostomy [36/437 (8.2%), P = 0.0001, OR 2.264 (1.49-3.46)]. CONCLUSIONS: Ileostomy formation is independently associated with kidney injury, with an increased risk persisting after stoma closure. Strategies to protect against kidney injury may be important in higher risk patients (elderly, receiving renin-angiotensin system antihypertensives, or following anastomotic leakage).

The effect of rectal washout on local recurrence following rectal cancer surgery.

Introduction Local recurrence after surgery for rectal cancer is associated with significant morbidity and debilitating symptoms. Intraoperative rectal washout has been linked to a reduction in local recurrence but there is no conclusive evidence. The aim of this study was to evaluate whether performing rectal washout had any effect on the incidence of local recurrence in patients undergoing anterior resection for rectal cancer in the context of the current surgical management. Methods A total of 395 consecutive patients who underwent anterior resection with or without rectal washout for rectal cancer between January 2003 and July 2009 at a high volume single institution were analysed retrospectively. A standardised process for performing washout was used and all patients had standardised surgery in the form of total mesorectal excision. Neoadjuvant and adjuvant therapy was used on a selected basis. Patients were followed up for five years and local recurrence rates were compared in the two groups. Results Of the 395 patients, 297 had rectal washout and 98 did not. Both groups were well matched with regard to various important clinical, operative and histopathological characteristics. Overall, the local recurrence rate was 5.3%. There was no significant difference in the incidence of local recurrence between the washout group (5.7%) and the no washout group (4.1%). Conclusions Among our cohort of patients, there was no statistical difference in the incidence of local recurrence after anterior resection with or without rectal washout. This suggests that other factors are more significant in the development of local recurrence.

Screen-detected colorectal cancers show improved cancer-specific survival when compared with cancers diagnosed via the 2-week suspected colorectal cancer referral guidelines.

AIM: Biennial screening for colorectal cancer using faecal occult blood testing has been shown to reduce the relative risk of mortality from colorectal cancer. The Norwich screening centre commenced screening in July 2006 and so far has diagnosed over 350 patients with colorectal cancer. We compared the stage at diagnosis and cancer-specific mortality and survival in patients diagnosed through screening with a cohort of symptomatic patients with colorectal cancer within the same age range. METHOD: A comparative analysis was undertaken of all screen-detected colorectal cancer patients diagnosed between July 2006 and December 2010, with an age-matched group of patients diagnosed in the Norfolk and Norwich Hospital through the 2-week suspected colorectal cancer guidelines. RESULTS: Three hundred and fifty-six cases of colorectal cancer were diagnosed through the screening programme, in patients with an age range of 60-79 years. In the same time period, 292 patients in the same age range were diagnosed with colorectal cancer through the 2-week suspected colorectal cancer pathway. Sixteen patients in the screening group had evidence of metastatic disease at presentation compared with 62 in the symptomatic group (χ(2) , P<0.001). The proportion of T1/T2 and Dukes A cancers was significantly greater in the screening group (χ(2) , P < 0.001). There were 21 colorectal cancer-related deaths in the screening group compared with 66 in the symptomatic group. Survival analysis curves showed significantly better survival in the screening group (log-rank analysis P<0.001). CONCLUSION: Screening for colorectal cancer identifies cancers at a significantly earlier stage than in symptomatic patients, with subsequent improvement in cancer-specific survival.

Nutrient intakes and foods selected by college students: comparisons among subgroups divided by energy intake.

Food consumption patterns of college students, divided into subgroups of men (no. = 58), women with mean energy intakes greater than 1,200 kcal (no. = 192), and women consuming less than 1,200 kcal (no. = 53), were studied using 3-day food records. Patterns of nutrient intakes, eating frequency, and types of food eaten differed among subgroups. Women with less than 1,200 kcal had lower intakes of protein, carbohydrate, fat, calcium, iron, thiamin, riboflavin, and niacin; they ate less frequently; and they ate less meat and eggs, legumes, bread, cooked starchy vegetables, milk products, desserts, added fat, and added sugar than did men and women whose mean energy intakes exceeded 1,200 kcal. There were differences between the latter two groups for 10 nutrients and for intakes of fluid milk, meat and eggs, legumes, bread, cooked starchy vegetables, alcoholic beverages, and noncarbonated, sweetened beverages. Diets of men met the RDAs for all nutrients calculated, and diets of women whose intakes exceeded 1,200 kcal met all RDAs except that for iron. Group mean intakes of women with less than 1,200 kcal did not meet the RDAs for calcium, iron, thiamin, riboflavin, and niacin. However, the subgroup with intakes less than 1,200 kcal consumed food of greater nutrient density than did other college students.