Background
Sexual and urinary dysfunction is an established risk after pelvic surgery. Studies examining sexual and urinary function following laparoscopic and open rectal surgery give conflicting ...evidence for outcomes. The purpose of this study was to analyse the impact of the surgical technique on functional outcomes following laparoscopic or open resection for rectal cancer patients in a high-volume laparoscopic unit.
Methods
All patients who underwent elective laparoscopic or open surgery for rectal cancer between September 2006 and September 2009 were identified from a prospectively collated database. Validated standardized postal questionnaires were sent to surviving patients to assess their postoperative sexual and urinary function. The functional data were then quantified using previously validated indices of function.
Results
A total of 173 patients were identified from the database, of whom 144 (83 %) responded to the questionnaire-based study. Seventy-eight respondents had undergone laparoscopic rectal resection (49 men and 29 women), and 65 had an open procedure (41 men and 24 women). Both open surgery and laparoscopic surgery were associated with deterioration in urinary and sexual function. With regard to urinary function, there was no difference in the deterioration in open and laparoscopic groups in either gender. With regard to sexual function, in males one component of sexual function, namely, the incidence of successful penetration, showed less deterioration in the laparoscopic group (
p
= 0.04). However, in females, laparoscopic surgery was associated with significantly better outcomes in all aspects of sexual activity, specifically sexual arousal (
p
= 0.005), lubrication (
p
= 0.001), orgasm (
p
= 0.04), and the incidence of dyspareunia (
p
= 0.02).
Conclusion
Laparoscopic total mesorectal excision for rectal cancer is associated with significantly less deterioration in sexual function compared with open surgery. This effect is particularly pronounced in women.
A laparoscopic approach to right colectomies for emergency right colon cancers is under investigation. This study compares perioperative and oncological long-term outcomes of right colon cancers ...undergoing laparoscopic or open emergency resections and identifies risk factors for survival.
Patients were identified from a prospectively maintained institutional database between 2009 and 2019. Demographics, clinicopathological features, recurrence, and survival were investigated. Cox regression analysis was performed for risk factor analysis.
A total of 202 right colectomies (114 open and 88 laparoscopic) were included. ASA III-IV was higher in the open group. The conversion rate was 14.8%. Laparoscopic surgery was significantly longer (156 vs. 203 min,
< 0.001); pTNM staging did not differ. Laparoscopy was associated with higher lymph node yield, and showed better resection clearance (R0, 78.9 vs. 87.5%,
= 0.049) and shorter postoperative stay (12.5 vs. 8.0 days,
< 0.001). Complication rates and grade were similar. The median length of follow-up was significantly higher in the laparoscopic group (20.5 vs. 33.5 months,
< 0.001). Recurrences were similar (34.2 vs. 36.4%). Open surgery had lower five-year overall survival (OS, 27.1 vs. 51.7%,
= 0.001). Five-year disease-free survival was similar (DFS, 55.8 vs. 56.5%). Surgical approach, pN, pM, retrieved LNs, R stage, and complication severity were risk factors for OS upon multivariate analysis. Pathological N stage and R stage were risk factors for DFS upon multivariate analysis.
A laparoscopic approach to right colon cancers in an emergency setting is safe in terms of perioperative and long-term oncological outcomes. Randomized control trials are required to further investigate these results.
Background
Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open ...resection for colon cancers treated as emergencies.
Methods
The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan–Meier curves.
Results
During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 95 % confidence interval (CI) 2.3–4.3 years. The overall 3-year survival rate was 51 % (95 % CI 35–76) in the laparoscopic group versus 43 % (95 % CI 32–58) in the open group (
p
= 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20–60) versus 37 % (95 % CI 27–50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes;
p
= 0.041) and median length of hospital stay (7.5 vs. 11.0 days;
p
= 0.019) favored laparoscopy.
Conclusions
Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.
At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal rectal cancer. The transanal ...part of the procedure is less hampered by patient related factors such as visceral obesity and a narrow bony pelvis and can thus overcome access and visualization problems encountered with a pure abdominal approach. Clearly, as for any new technique, a learning curve needs to be negotiated, ideally without unacceptable harm to patients. In experienced hands, TaTME might overcome challenges found in anatomically challenging rectal cancer patients as well as for other indications. The role of TaTME is not to replace, but rather complement its abdominal counterpart.
•In experienced hands Transanal Total Mesorectal Excision (TaTME) is a safe procedure.•TaTME can lead to less conversion with good specimen quality.•TaTME is meant for the most challenging group of rectal cancer patients.•Indications for TaTME are; high BMI, narrow pelvis, low tumor and bulky tumor.Long term results beyond the learning curve have to be awaited to show non-inferiority.
A needle was retained during transanal hemorrhoidal dearterialization. This rare complication has not been described before.
A spinal needle was inserted from the perianal skin to localize the ...retained foreign body that was located at 7 cm from the anal margin. A decision was made to proceed to intersphincteric dissection, and a 3-cm incision was made in the perianal skin from 2 to 4 o'clock. Deep pararectal dissection continued, and the needle was eventually found lying in the muscular layer, parallel to the plane of the dissection.
The needle was retrieved intact, and repeat x-ray confirmed that no foreign body was retained. The patient made an uneventful recovery and was discharged home on postoperative day 1 with a 5-day course of oral antibiotics; she was examined in clinic 4 weeks following surgery and reported significant symptomatic improvement with no perianal pain or rectal bleeding. No anal fistula was found on the examination.
X-ray guidance is a helpful adjunct to facilitate 3-dimensional localization. Intersphincteric dissection is a reliable alternative to the transanal approach, particularly when the needle cannot be seen arising from the mucosa or felt on palpation. Repeated attempts to palpate the needle should be avoided, because there is a potential risk of displacing it deeper or higher, making retrieval more difficult.
This systematic review and meta-analysis aimed to compare outcomes between stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA with mucosectomy in cases of ulcerative colitis and familial ...adenomatous polyposis.
This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines 2020 and AMSTAR 2 (Assessing the methodological quality of systematic reviews) guidelines. We included randomized clinical trials (RCTs) and controlled clinical trials (CCTs). Subgroup analysis was performed according to the indication for surgery.
The bibliographic research yielded 31 trials: 3 RCTs, 5 prospective clinical trials, and 24 CCTs including 8872 patients: 4871 patients in the stapled group and 4038 in the hand-sewn group. Regarding postoperative outcomes, the stapled group had a lower rate of anastomotic stricture, small bowel obstruction, and ileal pouch failure. There were no differences between the 2 groups in terms of operative time, anastomotic leak, pelvic sepsis, pouchitis, or hospital stay. For functional outcomes, the stapled group was associated with greater outcomes in terms of seepage per day and by night, pad use, night incontinence, resting pressure, and squeeze pressure. There were no differences in stool Frequency per 24h, stool frequency at night, antidiarrheal medication, sexual impotence, or length of the high-pressure zone. There was no difference between the 2 groups in terms of dysplasia and neoplasia.
Compared to hand-sewn anastomosis, stapled ileoanal anastomosis leads to a large reduction in anastomotic stricture, small bowel obstruction, ileal pouch failure, seepage by day and night, pad use, and night incontinence. This may ensure a higher resting pressure and squeeze pressure in manometry evaluation.
The protocol was registered at PROSPERO under CRD 42022379880.
While interest in elective robotic surgery is growing, use in emergency setting remains limited due to challenges posed by sicker patients, advanced pathology and logistical issues. During the ...COVID-19 pandemic, robotic surgery could provide the benefit of having the surgeon away from the bedside and reducing the number of directly exposed medical staff. The objective of this study was to report patient outcomes and initial learning experience of emergency robotic colorectal surgery during the COVID-19 pandemic.
A case series study was conducted, including patients undergoing emergency robotic colorectal surgery between February 2020 and February 2021 at Queen Alexandra Hospital in Portsmouth, UK. Patient data were collected from an ethics approved prospective database. Patient demographics, operative time, conversions and postoperative complications were recorded. In addition, readmissions, length of stay and short-term oncological outcomes were analyzed.
Ten patients with median age 64 y (range, 36–83 y) were included. Four patients had robotic complete mesocolic resection for obstructing cancers. Six had colorectal resections for benign disease in emergency setting. All were R0 with a mean lymph node harvest of 54 ± 13. Mean operative time was 249 ± 117 min, the median length of stay was 9.4 d (range, 5–22 d). Only one patient was given a temporary diverting ileostomy. There were no grade III/V complications and no 30-day mortality.
Provided an experienced team and peri-operative planning, emergency robotic colorectal surgery can achieve favorable outcomes with benefits of radical lymph node dissection in oncological cases and avoidance of diverting stoma.
Data analytics and artificial intelligence (AI) have been used to predict patient outcomes after colorectal cancer surgery. A prospectively maintained colorectal cancer database was used, covering ...4336 patients who underwent colorectal cancer surgery between 2003 and 2019. The 47 patient parameters included demographics, peri- and post-operative outcomes, surgical approaches, complications, and mortality. Data analytics were used to compare the importance of each variable and AI prediction models were built for length of stay (LOS), readmission, and mortality. Accuracies of at least 80% have been achieved. The significant predictors of LOS were age, ASA grade, operative time, presence or absence of a stoma, robotic or laparoscopic approach to surgery, and complications. The model with support vector regression (SVR) algorithms predicted the LOS with an accuracy of 83% and mean absolute error (MAE) of 9.69 days. The significant predictors of readmission were age, laparoscopic procedure, stoma performed, preoperative nodal (N) stage, operation time, operation mode, previous surgery type, LOS, and the specific procedure. A BI-LSTM model predicted readmission with 87.5% accuracy, 84% sensitivity, and 90% specificity. The significant predictors of mortality were age, ASA grade, BMI, the formation of a stoma, preoperative TNM staging, neoadjuvant chemotherapy, curative resection, and LOS. Classification predictive modelling predicted three different colorectal cancer mortality measures (overall mortality, and 31- and 91-days mortality) with 80–96% accuracy, 84–93% sensitivity, and 75–100% specificity. A model using all variables performed only slightly better than one that used just the most significant ones.
Background
The surgical treatment options for low rectal cancer patients include the Abdominoperineal Resection and the sphincter saving Low Anterior Resection. There is growing evidence towards ...better outcomes for patients being treated with a Low Anterior Resection compared to an Abdominoperineal Resection.
Objective
The aim of this study was to evaluate the short term and oncological outcomes in low rectal cancer treatment.
Design
This is a retrospective cohort study of prospectively collected data.
Setting
Rectal cancer patients from a single center in the United Kingdom.
Patients
Patients included all low rectal cancer patients (≤ 6 cm from the anal verge) undergoing Low Anterior Resection or Abdominoperineal Resection between 2006 and 2016.
Outcome measures
To identify differences in postoperative complications and disease free and overall survival.
Results
A total of 262 patients were included for analysis (Low Anterior Resection n = 170, Abdominoperineal Resection n = 92). Abdominoperineal Resection patients were significantly older (69 versus 66 years), had lower tumours (3 versus 5 cm), received more neo-adjuvant radiation, had longer hospital stay and more complications (wound infections and wound dehiscence). Low Anterior Resections had a significantly higher number of harvested lymph nodes (17 versus 12) however there was no difference in nodal involvement and R0 resection rate. No significant difference was found for recurrence, overall survival and disease free survival.
Limitation
Retrospective review of cancer database and single center data.
Conclusion
In the treatment of low rectal cancer Abdominoperineal Resection is associated with higher rates of postoperative complications and longer hospital stay compared to the Low Anterior Resection, with similar oncological outcomes.
Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported ...in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery.
This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus.
Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations.
Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.
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