Short- and long-term outcomes of strictureplasty for obstructive Crohn's disease.

AIM: To evaluate the frequency and outcome of strictureplasty in the era of biologicals and to compare patients operated on by strictureplasty alone, resection alone or a combination of both. METHOD: A retrospective review of all patients undergoing strictureplasty for obstructing jejunoileal Crohn's disease (CD) in Oxford between 2004 and 2016 was conducted. For comparison, a cohort of CD patients with resection only during 2009 and 2010 was included. RESULTS: In all, 225 strictureplasties were performed during 85 operations, 37 of them in isolation and 48 with simultaneous resection. Another 82 procedures involved resection only; these patients had shorter disease duration, fewer previous operations and longer bowel preoperatively. The frequency of strictureplasty procedures did not alter during the study period and was similar to that in the preceding 25 years. There was no postoperative mortality. One patient required re-laparotomy for a leak after strictureplasty. None developed cancer. The 5-year reoperation rate for recurrent obstruction was 22% (95% CI 12-39) for resection alone, 30% (17-52) for strictureplasty alone and 42% (27-61) for strictureplasty and resection (log rank P = 0.038). Young age was a risk factor for surgical recurrence (log rank P = 0.006). CONCLUSION: The use of strictureplasty in CD has not changed significantly since the widespread introduction of biologicals. Surgical morbidity remains low. The risk of recurrent strictures is high and young age is a risk factor. In this study, strictureplasty alone was associated with a lower rate of reoperation compared with strictureplasty with resection.

Development and early outcomes of the national training initiative for transanal total mesorectal excision in the UK.

AIM: Transanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorectal surgeons but its technical challenges may underlie the early reports of visceral injuries and oncological concerns. The aim of this study was to report on the feasibility, development and the outcome of the national pilot training initiative for TaTME-UK. METHODS: TaTME-UK was successfully launched in September 2017 in partnership with the healthcare industry and endorsed by the Association of Coloproctology of Great Britain and Ireland. This multi-modal training curriculum consisted of three phases: (i) set-up; (ii) selection of pilot sites; and (iii) formal proctorship programme. Bespoke Global Assessment Scoring (GAS) forms were designed and completed by both trainees and mentors. Data were collected on patient demographics, tumour characteristics and perioperative clinical and histological outcomes. RESULTS: Twenty-four proctored cases were performed by 10 colorectal surgeons from five selected pilot sites. Median operative time was 331 ± 90 (195-610) min which was reduced to 283 ± 62 (195-340) min in the final case. Independent performance (GAS score of 5) was achieved for most operative steps by case 5. There was one conversion (4.2%), but no visceral injuries. Pathological data confirmed no bowel perforation and intact quality of the mesorectal TME specimens with clear distal margin in all cases and circumferential margins in 23/24 cases (96%). CONCLUSION: This exploratory study demonstrates acceptable early outcomes in a small cohort suggesting that a competency-based multi-modal training programme for TaTME can be feasible and safe to implement at a national level.

Multicentre phase II trial of near-infrared imaging in elective colorectal surgery.

BACKGROUND: Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery. METHODS: This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone. RESULTS: Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology. CONCLUSION: Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.

Subtotal colectomy for ulcerative colitis: lessons learned from a tertiary centre.

AIM: Subtotal colectomy (STC) is a well-established treatment for complicated and refractory ulcerative colitis (UC). A laparoscopic approach offers potentially improved outcomes. The aim of the study was to report our experience with STC for UC in a single large centre. METHOD: From January 2007 to May 2015, all consecutive patients undergoing STC for UC were retrospectively analysed from a prospectively managed database. Patients with known Crohn's disease or those undergoing one-stage procedures were excluded. Demographics, perioperative outcomes and second-stage procedures were analysed. RESULTS: During the study period, 151 STCs were performed for UC [100 emergency (66%) and 51 elective (34%)]. Acute severe colitis refractory to therapy was the most common indication (62%). Overall, 117 laparoscopic (78%) and 34 open STCs were performed, with a conversion rate of 14.5%. Mortality and morbidity rates were 0.7% and 38%, respectively. Whilst operative time was shorter for open STC (by 75 min; P = 0.001), there were fewer complications (32% vs 62%; P = 0.002) and a shorter hospital stay (by 6.9 days; P = 0.0002) following laparoscopic STC. Fewer complications and shorter hospital stay were also observed after elective STC. Patients undergoing laparoscopic STC were more likely to undergo a restorative second-stage procedure than those having open STC (75% vs 50%; P = 0.03). CONCLUSION: Laparoscopic STC for UC is feasible and safe, even in the emergency situation. A laparoscopic approach may offer advantages in terms of lower morbidity and reduced length of stay. Elective resection may offer similar advantages and is best performed whenever possible.

The treatment of all MRI-defined low rectal cancers in a single expert centre over a 5-year period: is there room for improvement?

AIM: Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition. METHOD: A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database. RESULTS: One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response. CONCLUSION: In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers.

A two-centre experience of transanal total mesorectal excision.

AIM: Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two-centre experience of this technique, focusing on the short-term and oncological outcome. METHOD: From May 2013 to May 2015, 40 selected patients with histologically proven rectal adenocarcinoma underwent TaTME in two institutions and were prospectively entered on an online international registry. RESULTS: Forty patients (80% men, mean body mass index 27.4 kg/m2 ) requiring TME underwent TaTME. Procedures included low anterior resection (n = 31), abdominoperineal excision (n = 7) and proctocolectomy (n = 2). A minimally invasive approach was attempted in all cases, with three conversions. The mean operation time was 368 min and 16 patients (40%) had a synchronous abdominal and transanal approach. There was no mortality and 16 postoperative complications occurred, of which 68.8% were minor. The median length of stay was 7.5 (3-92) days. A complete or near-complete TME specimen was delivered in 39 (97.5%) cases with a mean number of 20 lymph nodes harvested. R0 resection was achieved in 38 (95%) patients. After a median follow-up of 10.7 months, there were no local recurrences and six (15%) patients had developed distant metastases. CONCLUSION: TaTME appears to be feasible, safe and reproducible, without compromising the oncological principles of rectal cancer surgery. It is an attractive option for patients for whom laparoscopy is likely to be particularly difficult. These encouraging results should encourage larger studies with assessment of long-term function and the oncological outcome.

Four anastomotic techniques following transanal total mesorectal excision (TaTME).

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.

Transanal rectal resection: an initial experience of 20 cases.

AIM: Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique. METHOD: From June 2013 to September 2014, 20 selected patients underwent transanal rectal resection for various malignant and benign low rectal pathologies. All patients with rectal cancer were discussed at a multidisciplinary team meeting. Data were entered into a prospective managed international database. RESULTS: Of the 20 patients (14 male), seventeen (85%) had rectal cancer lying at a median distance of 2 cm (range 0-7) from the anorectal junction. The operations performed included LAR (16). Abdominoperineal excision (2) and completion proctectomy (2), all of which were performed by a minimally invasive approach with three conversions. The mean operation time was 315.3 min. There were six postoperative complications of which two (10%) were Clavien-Dindo Grade IIIb (pelvic haematoma and a late contained anastomotic leakage). The median length of stay was 7 days. The TME specimen was intact in 94.1% of cancer cases. The mean number of harvested lymph nodes was 23.2. There was only one positive circumferential resection margin (tumour deposit; R1 rate 5.9%). One patient developed a distant recurrence (median follow-up 10 months, range 6-21). CONCLUSION: TaTME was safe in this small series of patients. It is especially attractive in patients with a narrow and irradiated pelvis and a tumour in the lower third of the rectum. TaTME is technically demanding, but the good outcomes should prompt randomized studies and prospective registration of all taTME cases in an international registry.

Endoscopically assisted extralevator abdominoperineal excision.

AIM: Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position. METHOD: Three male patients with a rectal tumour located at the anorectal junction underwent an endoscopically assisted ELAPE in the lithotomy position after preoperative radiotherapy. RESULTS: All the procedures were performed successfully with operation times of 180, 390 and 420 mins. There were no instances of intra-operative perforation or other complications. One patient developed postoperative intestinal obstruction which resolved on conservative management. There were no wound complications. Histopathological examination demonstrated clear margins and intact mesorectal planes in each patient. CONCLUSION: We report a good outcome in three patients after endoscopically assisted ELAPE. This approach allows the patient to be operated on in the lithotomy position giving excellent views of the anterior dissection.

Fluorescence angiography in laparoscopic low rectal and anorectal anastomoses with pinpoint perfusion imaging--a critical appraisal with specific focus on leak risk reduction.

BACKGROUND AND AIMS: Anastomotic dehiscence is one of the most feared complications in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. One of the key factors is the perfusion of the bowel to be joined. Presently, surgeons rely on a variety subjective measures to determine anastomotic perfusion and mechanical integrity however these have shortcomings. The aim of this paper is to appraise the literature on the use of fluorescence angiography (FA) in laparoscopic rectal surgery. MATERIALS AND METHODS: A Pubmed search was undertaken using terms 'fluorescence angiography' and 'rectal surgery'. The search was expanded using the related articles function. Studies were included if they used FA specifically for rectal surgery. Outcomes of interest including anastomotic leak rate, change of operative strategy and time taken for FA were recorded. RESULTS: Eleven papers detailing the use of FA in rectal surgery are outlined demonstrating that this technique may change operative strategy and lead to a reduction in anastomotic leak rate. CONCLUSION: In this paper, we discuss assessment of colorectal blood supply using FA and how this technique holds great potential to detect insufficiently perfused bowel. In so doing, the operator can adjust their operative strategy to mitigate these affects with the aim of reducing the complications of anastomotic leak and stenosis. However, it is highlighted that there is a clear need for randomised controlled trials in order to determine this definitively.

Discriminatory influence of Pinpoint perfusion imaging on diversion ileostomy after laparoscopic low anterior resection.

While still debated, it was advised to perform a protective temporary ileostomy after a low anterior resection (LAR). This might help to decrease the leak rate and therefore offers the patient better outcomes. Anastomotic leak can occur in many situations after a LAR and the control of the risk factors helps to adapt the need of an ileostomy. Near infrared technology allows assessing the microvascularisation of the anastomosis at the time of surgery and therefore might be an important tool to avoid a stoma in given situation. This article reviews the evidences with the use of this technology.

Myenteric plexitis at the proximal resection margin is a predictive marker for surgical recurrence of ileocaecal Crohn's disease.

AIM: Identifying predictors for the recurrence of Crohn's disease (CD) after surgery to improve disease surveillance or targeted therapy is rational. The purpose of this study was to examine the relationship between myenteric plexitis (MP) and clinical or surgical recurrence. METHOD: Between 2000 and 2010, patients who underwent primary ileocaecal resection for CD at a single tertiary referral centre were identified. The histopathology was retrospectively reviewed for MP at the resection margins. The severity of MP was graded from 0 to 3 using a previously described classification. Information on demographics, surgical details and evidence of clinical or surgical recurrence was obtained from medical records. RESULTS: There were 86 patients (49 women) of median age 31.5 (interquartile ratio 23.5-41.0) years. Seventy-six and 77 specimens were assessable for proximal and distal MP. Proximal MP was present in 53 (69.7%) patients and was classified as mild, moderate or severe in 30 (39.5%), 14 (18.4) and nine (11.8%). MP at the distal resection margin was present in 40 (51.9%). Forty (46.5%) patients developed clinical recurrence of whom 16 (18.6%) required surgery. Clinical factors that predicted recurrence included age > 40 (P = 0.001) and the presence of an anastomosis (P = 0.023). On univariate analysis severe plexitis (Grade 3 MP) was also associated with surgical recurrence (P = 0.035). CONCLUSION: This retrospective study supports the association between MP at the proximal resection margin and surgical recurrence.

Assessment of the quality of patient-orientated internet information on surgery for ulcerative colitis.

AIM: This study examines the quality of websites providing information on ulcerative colitis, including treatment options and surgery. METHOD: Two search engines (Google and Yahoo) and the search term 'surgery for ulcerative colitis' were used. The first 50 sites obtained with each search engine were assessed. Sites were evaluated for content and scored using the DISCERN instrument, which evaluates the quality of health information on treatment choices. RESULTS: One hundred sites were examined, of which 14 were duplicates. Of the remainder, 58 provided patient-orientated information for adults and one site provided information for surgery in children. The other 27 sites included six scientific articles, three blogs, three links, six resources for clinicians, five fora, two video links and two dead links. Of the 58 websites that provided patient information for adults, only 26 (44.8%) had been updated within the last 2 years. Only 13/58 (22.4%) were affiliated to hospitals and clinics. Most sites (38/58, 65.5%) were associated with private companies with commercial interests. Although most websites contained information on symptoms and treatment options for ulcerative colitis, 37 (63.8%) did not describe any of the risks of surgery. Overall, only seven (12.1%) websites were identified as being 'good' or 'excellent' using the DISCERN criteria. CONCLUSION: The quality of patient information on surgery for ulcerative colitis is highly variable. There is potential for internet provision of valuable information and clinicians should guide patients with to access high-quality websites.

Evaluation of quality of life and function at 1 year after transanal endoscopic microsurgery.

AIM: Transanal endoscopic microsurgery (TEM) enables organ preservation after rectal tumour surgery. Its application is being expanded using adjuvant and neoadjuvant treatments. Our objective was to evaluate the changes over time in anorectal function, urinary symptoms and quality of life (QoL) in patients who had TEM surgery for a rectal tumour. METHOD: Between September 2009 and October 2012, a consecutive series of 102 patients underwent TEM at a single institution. Patients were asked to fill out standardized questionnaires at baseline and then at 6, 12, 26 and 52 weeks after surgery. The QoL among these patients was assessed using one generic (EQ-5D) and two disease-specific [European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR29] questionnaires. Anorectal and urinary symptoms were studied using the COlo-REctal Functional Outcome (COREFO) and the International Prostate Symptom Score (I-PSS) questionnaires, respectively. RESULTS: The response rate was 90% (92/102 patients). Postoperative complications occurred in 14% (13/92) of patients. The general QoL (as assessed using the EQ-5D) was lower 6 and 12 weeks after TEM compared with baseline QoL (P < 0.05) but returned towards baseline after 26 weeks. Anorectal function (determined using the COREFO) was worse 6 weeks postoperatively (P < 0.01) but had normalized by 12 weeks. Urinary function (determined using the I-PSS) was not affected at any time point after surgery. The total COREFO score and the American Society of Anesthesiologists (ASA) score were correlated with the deterioration in QoL. CONCLUSION: The study demonstrates that TEM has a temporary and reversible impact on QoL and anorectal function. Intensive interrogation of QoL and function using appropriate questionnaires will help to define the role of organ-preserving surgery for rectal cancer before and after chemoradiotherapy.

How useful is endorectal ultrasound in the management of early rectal carcinoma?

INTRODUCTION: Endorectal ultrasonography (EUS) is used to T stage early rectal tumours and select patients to whom transanal endoscopic microsurgery (TEM) could be offered. Published papers have shown that EUS can have good accuracy, but there is little literature on how EUS influences patient management. The study aim is to ascertain the value of EUS in the management of early rectal tumours. METHODS: Patients with adenomas/early rectal carcinoma being considered for TEM were prospectively studied. Each patient underwent EUS. The surgeon recorded the expected T stage, confidence level of the T stage and management plan for each patient on a proforma before and after the ultrasound result was revealed. Comparison was made between the ultrasound stage and final pathological stage where available. RESULTS: Ninety-six patients were referred over 2 years. Nine were out of reach of the rigid probe and were excluded. Proformas were completed on 53/87 patients (age range 28-87 years, mean age 66 years, 30 males/23 females). Forty-eight patients had a pathological report to compare with the EUS T stage. Ultrasound agreed with the pathological T staging in 43 patients (90%). Patient management was changed in five patients. In 30% of (16/53) patients, EUS increased the confidence level for T staging. CONCLUSION: Although EUS has a high accuracy in predicting the T stage of early rectal cancers, it never changes the management plan for lesions thought to be benign. It seldom changes the pre-operative selection process when clinical examination is considered with other imaging modalities (MRI/CT). EUS should be reserved for answering specific questions in difficult cases rather than for all patients.

Robotic transanal minimally invasive surgery for local excision of rectal neoplasms.

BACKGROUND: Robotic transanal minimally invasive surgery (TAMIS) may be an option for rectum-preserving excision of neoplasms. Recent cadaveric studies showed improved vision, control and manoeuvrability compared with use of laparoscopic instruments. This study reports the clinical application. METHODS: Consecutive patients eligible for transanal endoscopic microsurgery (TEM) or TAMIS in three participating centres were operated on using a robotic platform and transanal glove port. Patient demographics, lesion characteristics, perioperative data, complications and follow-up of all patients were recorded prospectively. RESULTS: Sixteen patients underwent robotic TAMIS for rectal lesions with a median (range) distance from the anal verge of 8 (range 3-10) cm. The median size of the resected specimen was 5·3 (0·5-21) cm(2) . The median docking time and duration of operation were 36 (18-75) and 108 (40-180) min respectively. One conversion to regular (non-robotic) TAMIS was needed owing to difficulties accessing the rectum. Glove puncture necessitated replacement in four procedures, an unstable pneumorectum arose during one operation and one patient developed a pneumoperitoneum. One patient required catheterization for urinary retention. The median hospital stay was 1·3 (0-4) days. The additional cost of the robotic approach was approximately €1000 per procedure (excluding the capital expenditure on the robotic system and its maintenance). CONCLUSION: Robotic TAMIS is feasible in patients with rectal lesions. Potential advantages over TEM and non-robotic TAMIS will need to be balanced against the cost of the robotic system.