Right colectomy is the standard surgical treatment for tumors in the right colon and surgical complications are reduced with minimally-invasive laparoscopy compared with open surgery, with potential ...further benefits achieved with robotic assistance. The anastomotic technique used can also have an impact on patient outcomes. However, there are no large, prospective studies that have compared all techniques.
MIRCAST is the Minimally-Invasive Right Colectomy Anastomosis Study that will compare laparoscopy with robot-assisted surgery, using either intracorporeal or extracorporeal anastomosis, in a large prospective, observational, multicenter, parallel, four-cohort study in patients with a benign or malignant, non-metastatic tumor of the right colon. Over 2 years of follow-up, the study will prospectively evaluate peri- and postoperative complications, postoperative recovery, hospital stay, and mid-term results including survival, local recurrence, metastases rate, and conversion rate. The primary composite endpoint will be the efficacy of the surgical method regarding surgical wound infections and postoperative complications (Clavien-Dindo grade III-IV complications at 30 days post-surgery). Secondary endpoints include long-term oncologic results, conversion rate, operative time, length of stay, and quality of life.
This will be the first large, international study to prospectively evaluate the use of minimally-invasive laparoscopy or robot-assisted surgery during right hemicolectomy and to control for the impact of the anastomotic technique. The research will contribute to current knowledge regarding the medical care of patients with malignant or benign tumors of the right colon, and enable physicians to determine which technique may be the most appropriate for their patients.
This study was registered on Clinicaltrials.gov (clinicaltrials.gov identifier: NCT03650517 ) on August 28th 2018 (study protocol version CI18/02 revision A, 21 February 2018).
The aim of this study was to assess how age is related to differences in stage, tumour differentiation and treatment in colorectal cancer.
A retrospective study in a consecutive series of colorectal ...cancer patients (n = 2220) where age was related to demography, stage, tumour characteristics, treatment and outcome (OS/CSS) both as a continuous variable and grouped by high/low 10th percentiles, as young/old groups, with a third median reference group.
Young patients had more advanced cancer stages (p = 0.012), higher N-status (p = 0.011) and more frequent T4/G4 tumours. Old patients had higher postoperative mortality and were less likely to receive chemotherapy. The proportion of cancer-related deaths was stage-dependent and decreased with age.
Cancer stage, tumour characteristics, treatment and outcome can vary with age in colorectal cancer. The increasing proportion of non-cancer deaths at a higher age can affect the use of overall survival as an outcome parameter, which may be of importance in evaluating clinical and translational research.
Background
CME is a radical resection for colon cancer, but the procedure is technically demanding with significant variation in its practice. A standardised approach to the optimal technique and ...training is, therefore, desirable to minimise technical hazards and facilitate safe dissemination. The aim is to develop an expert consensus on the optimal technique for Complete Mesocolic Excision (CME) for right-sided and transverse colon cancer to guide safe implementation and training pathways.
Methods
Guidance was developed following a modified Delphi process to draw consensus from 55 international experts in CME and surgical education representing 18 countries. Domain topics were formulated and subdivided into questions pertinent to different aspects of CME practice. A three-round Delphi voting on 25 statements based on the specific questions and 70% agreement was considered as consensus.
Results
Twenty-three recommendations for CME procedure were agreed on, describing the technique and optimal training pathway. CME is recommended as the standard of care resection for locally advanced colon cancer. The essential components are central vascular ligation, exposure of the superior mesenteric vein and excision of an intact mesocolon. Key anatomical landmarks to perform a safe CME dissection include identification of the ileocolic pedicle, superior mesenteric vein and root of the mesocolon. A proficiency-based multimodal training curriculum for CME was proposed including a formal proctorship programme.
Conclusions
Consensus on standardisation of technique and training framework for complete mesocolic excision was agreed upon by a panel of experts to guide current practice and provide a quality control framework for future studies.
Aim
Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency‐based training programme ...through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons.
Method
A Delphi questionnaire with a 72‐item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval.
Results
The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75–1).
Conclusion
This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.
Aim
The aim was to develop and operationally define ‘performance metrics’ that characterize a reference approach to robotic‐assisted low anterior resection (RA‐LAR) and to obtain face and content ...validity through a consensus meeting.
Method
Three senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers’ instructions and unedited videos of RA‐LAR to deconstruct the operation into defined, measurable components – performance metrics (i.e. procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified Delphi process.
Results
Performance metrics for RA‐LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in women, 88 errors and 118 critical errors in men. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in women, 87 errors and 116 critical errors in men. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from phase I (patient positioning and preparation, 83%) and phase IV (docking, 94%).
Conclusion
A robotic rectal operation can be broken down into procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardized procedural assessment for RA‐LAR.
Purpose Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse ...and external component, and evaluated its correlation to symptoms before and after surgery.
Method A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self‐report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self‐reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential.
Results Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively.
Conclusion This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.
Aim The long‐term results of stapled haemorrhoidopexy for prolapsed haemorrhoids were assessed using uniform methods to acquire data and pre‐set definitions of failure, recurrence, residual symptoms ...and impaired continence.
Method From October 1999 to May 2005, 153 patients underwent a stapled haemorrhoidopexy and were enrolled prospectively. They were assessed preoperatively, postoperatively and at the end of the study from replies to a questionnaire about symptoms and continence. Preoperatively, manual reduction of prolapse was required in 103 patients, skin tags were found in 115 patients (circumferential in 22) and impaired continence in 63.
Results In all, 145 patients completed preoperative and long‐term protocols and were analysed as paired data, at a mean follow‐up of 32 months. Failure to control the prolapse or recurrence was seen in 19 (13%) patients including nine reoperations for prolapse. Symptoms improved from 8.1 to 2.5 points on a 15‐point scale (P = 0.001). Symptoms were not controlled in 25 (17%) patients. Continence improved from 4.7 to 2.9 points on a 15‐point scale (P = 0.001). Twenty‐five (17%) patients still had a continence disturbance. Altogether 51 (35%) patients had a deficient outcome with respect to prolapse, symptoms or continence. There were no major adverse events.
Conclusion Restoration of the anal anatomy by stapled haemorrhoidopexy resulted in a significant improvement in haemorrhoid‐associated symptoms and continence but a third of patients had poor symptom control including 13% with persisting prolapse.
Objective We studied whether excision of residual external skin tags causes additional pain in patients undergoing a stapled anopexy for muco‐anal prolapse.
Method Seventeen patients in whom skin ...tags had been excised were compared with 24 patients having no excision. The patients were selected from a prospective database of haemorrhoid surgery if they had submitted a diary with self‐reported postoperative pain scores as well as a self‐reported symptom questionnaire preoperatively and postoperatively. The tags were excised with preservation of the subdermal fascia.
Results There were 41 patients who fulfilled the criteria for inclusion. Seventeen (group 1) had tags excised and 24 (group 2) did not. Fifty‐nine per cent in group 1 and 67% in group 2 experienced preoperative prolapse needing manual reposition. The mean height of the staple line was 2 cm above the dentate line in both groups. Daily average postoperative pain recorded as the sum of a self‐reported VAS rating over 14 days was 26 points in both groups. The peak pain experienced was 42 and 43 points respectively (not significant). Resolution of postoperative pain over 14 days was identical. The preoperative and postoperative symptom score was comparable in both groups.
Conclusion Excision of anal skin tags should be carried out at the time of stapled anopexy.
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