Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis.

BACKGROUND: Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection. METHOD: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates. RESULTS: Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias. CONCLUSION: Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.

Robotic versus laparoscopic right hemicolectomy: a retrospective cohort study of the Binational Colorectal Cancer Database.

Robotic right hemicolectomy (RRC) may have technical advantages over the conventional laparoscopic right colectomy (LRC) due to higher degrees of rotation, articulation, and tri-dimensional imaging. There is growing literature describing advantages of RRC compared to LRC; however, there is a lack of evidence about safety, oncologic quality of surgery and cost. This study aimed to analyse complication rates, length of stay and nodal harvest in patients undergoing minimally invasive right hemicolectomy for colon cancer from a prospective Australasian colorectal cancer database. This was a retrospective cohort study using nearest neighbour matching. The Binational Colorectal Cancer Audit (BCCA) provided the data for analysis. The primary outcome was length of stay. Secondary outcomes were harvested lymph node count, anastomotic leak, postoperative haemorrhage, abdominal abscess, postoperative ileus, wound infections and non-surgical complications. 4977 patients who underwent robotic (n = 146) or laparoscopic (n = 4831) right hemicolectomy for right-sided colon cancer were included. For RRC, LOS was shorter (5 vs 6.9 days, p = 0.01) and nodal harvest was higher (22 vs 19, p = 0.04). For RRC, surgical complications (5.9% vs 14.2%, p < 0.004) and non-surgical complications (4.6% vs 11.7%, p = 0.007) were lower though there was no difference in return to theatre or inpatient death. Robotic right hemicolectomy is associated shorter LOS and marginally higher lymph node count, though this may reflect anastomotic technique rather than surgical platform. Longer term studies are required to establish differences in overall survival, incisional hernia rates and cost effectiveness.

Review of research output of Australian and New Zealand colorectal surgeons over the past 20 years.

OBJECTIVES: High-quality research has a tangible impact on patient care and should inform all medical decision-makings. Appraising and benchmarking of research is necessary in evidence-based medicine and allocation of funding. The aim of this review is to demonstrate how evidence may be gathered by quantifying the amount and type of research by a group of surgeons over a 20-year period. METHODS: Members of the Colorectal Surgical Society of Australia and New Zealand were identified in April 2020. A search of the Scopus database was conducted to quantify each surgeon's research output from 1999 to 2020. Authorship details such as the Hirsch index and number of papers published were recorded, as were publication-related details. RESULTS: 226 colorectal surgeons were included for analysis, producing a total of 5053 publications. The most frequent colorectal topics were colorectal cancer (32%, n = 1617 of all publications), followed by pelvic floor disorders (4.3%, n = 217) and inflammatory bowel disease (3.5%, n = 177). 56% (n = 2830) of all publications were case series audits (21%, n = 1061), expert opinion pieces (20%, n = 1011) and cohort studies (15%, n = 758). 7% (n = 354) were randomised control or non-randomised control trials, 3% (n = 152) were systematic reviews and 1% (n = 50) were meta-analyses. The top 10% (n = 23) of authors accounted for more than half (54%, n = 2729) of manuscripts published. CONCLUSION: Australasian colorectal surgeons made a significant contribution to the medical literature over the past 20 years and the number of publications is increasing over time. A greater output of higher-level evidence research is needed. This information may be used to better allocate researcher funding and grants for future projects.

Silicone nipple discharge: A case report of an unusual presentation of breast implant rupture.

INTRODUCTION: Breast implant rupture is a well-documented complication of breast implant surgery. Diagnosis of ruptured silicone implants can be difficult due to the lack of overt symptoms. This is the first reported case of a patient with silicone breast implant rupture presenting with clear nipple discharge and is presented in line with SCARCE 2018 Guidelines [1]. PRESENTATION OF CASE: A 45-year-old-female was referred to a breast surgeon with viscous clear nipple discharge, on a background of bilateral mastopexy-augmentation surgery 10 years prior. Imaging revealed extensive intraductal and free silicone causing significant stromal deformity secondary to breast implant rupture. Cytology of the nipple discharge was consistent with silicone gel. The patient was also found to have fibroadenoma without atypia in the right breast. She underwent an oncoplastic excision of free silicone and change of bilateral breast implants by a team of breast and plastic surgeons. DISCUSSION: With breast implants being an increasingly common procedure worldwide, we can expect an increase in these unusual presentations. Clinicians and patients need to be aware of these in order to avoid an unnecessary delay in diagnosis. CONCLUSION: Silicone implant rupture is a well-known complication and the rate of rupture increases over the life of the implant. Diagnosis of ruptured silicone implants is rare on clinical examination however remains an essential component of a doctor's examination of the patient and nipple discharge must be considered a symptom of rupture.

Blood Pressure and Early Mobilization After Total Hip and Knee Replacements: A Pilot Study on the Impact of Midodrine Hydrochloride.

BACKGROUND: Early mobilization is an important therapeutic goal after total knee replacement and total hip replacement. Orthostatic hypotension and orthostatic intolerance can impede mobilization. Midodrine hydrochloride, an orally administered vasoconstrictor, may improve blood pressure and diminish the prevalence of adverse mobilization events. METHODS: We conducted a pilot change-of-practice study. Two cohorts, each comprising 10 patients managed with total knee replacement and 10 patients managed with total hip replacement, were managed with blood pressure-adjusted midodrine, which was administered 3 times daily for the first 72 hours postoperatively at either a low dose (2.5 or 5 mg) or a higher dose (5 or 10 mg). These patients were then matched with an equivalent preintervention cohort of patients. RESULTS: The midodrine protocol was instituted effectively and with high compliance. Hypotension was uncommon across all groups, with the mean lowest systolic blood pressure ranging from 110 to 121 mm Hg. Moreover, adverse mobilization events were uncommon across all groups (prevalence, 9.6% in the control group, 5.6% in the low-dose group, and 2.9% in the high-dose group) (p = 0.046 for the high-dose group versus the control group). A midodrine dose of 10 mg generated a significant mean dose-related systolic blood pressure increase of 14 mm Hg at 2 hours after administration (p < 0.001). There were no significant differences between the groups in terms of mean systolic blood pressure, biochemical markers, or intravenous therapy administration. CONCLUSIONS: A dose of 10 mg was found to achieve a significant systolic blood pressure response at 2 hours after administration and, in patients who received higher-dose midodrine, adverse mobilization events appeared less common. Additional investigation with a blinded randomized controlled trial, utilizing 10 mg of midodrine 2 hours before mobilization, would be needed to confirm the efficacy of midodrine therapy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.