Electrical spinal cord neuromodulation has emerged as a leading intervention for restoring autonomic functions, such as blood pressure, lower urinary tract (LUT), bowel, and sexual functions, ...following spinal cord injury (SCI). While a few preliminary studies have shown the potential effect of non-invasive transcutaneous spinal cord stimulation (tSCS) on autonomic recovery following SCI, the optimal stimulation parameters, as well as real-time and long-term functional benefits of tSCS are understudied. This trial entitled "Non-invasive Neuromodulation to Treat Bladder, Bowel, and Sexual Dysfunction following Spinal Cord Injury" is a pilot trial to examine the feasibility, dosage effect and safety of tSCS on pelvic organ function for future large-scale randomized controlled trials.
Forty eligible participants with chronic cervical or upper thoracic motor-complete SCI will undergo stimulation mapping and assessment batteries to determine the real-time effect of tSCS on autonomic functions. Thereafter, participants will be randomly assigned to either moderate or intensive tSCS groups to test the dosage effect of long-term stimulation on autonomic parameters. Participants in each group will receive 60 minutes of tSCS per session either twice (moderate) or five (intensive) times per week, over a period of six weeks. Outcome measures include: (a) changes in bladder capacity through urodynamic studies during real-time and after long-term tSCS, and (b) resting anorectal pressure determined via anorectal manometry during real-time tSCS. We also measure assessments of sexual function, neurological impairments, and health-related quality of life using validated questionnaires and semi-structured interviews.
Ethical approval has been obtained (CREB H20-01163). All primary and secondary outcome data will be submitted to peer-reviewed journals and disseminated among the broader scientific community and stakeholders.
Purpose
Postoperative urinary retention (POUR) is a known morbidity after colorectal surgery. This study investigated the effect of prophylactic tamsulosin on urinary retention rates after colorectal ...surgery.
Methods
A retrospective cohort study of male patients 50 years or older undergoing elective colonic and rectal resections from May 2014 to November 2019 was performed. The intervention assessed was prophylactic tamsulosin use. POUR, defined by requiring intermittent or reinsertion of urinary catheter, was compared using chi-squared analysis.
Results
A total of 332 patients were included, 131 received no tamsulosin, and 201 received prophylactic tamsulosin. Overall POUR was significantly reduced (16.8% vs. 9.5%,
p
= 0.047). Subgroup analysis for age 50–59 revealed no difference (9.1% vs. 9.4%,
p
= 0.96), but POUR risk was significantly lower in age 60 and older (20.7% vs. 9.5%,
p
= 0.02). No significant difference was found in rectal resections alone (18.2% vs. 13.2%,
p
= 0.34).
Conclusion
Prophylactic tamsulosin reduced POUR after colorectal surgery with the greatest effect in men 60 years or older and colonic resections.
Surgical site infections of up to 27% are reported for colorectal surgery. Care bundles have been introduced to decrease surgical site infection rates, but are variable in composition.
This study ...aimed to determine whether the addition of a "Colorectal Closure Bundle" in our Enhanced Recovery After Surgery pathway decreased surgical site infection rates.
This is a retrospective study of elective colon resections before and after the addition of a closure bundle.
This study was conducted at a single academic institution.
Patients undergoing consecutive elective colon resections with primary anastomosis, December 2012 to July 31, 2014, enrolled in our Enhanced Recovery After Surgery pathway. Exclusion criteria were stoma creation and closure and preoperative chemoradiation.
The "Colorectal Closure Bundle," which includes a change in gown and gloves, redraping, wound lavage, and a new set of instruments for closure, was added to the Enhanced Recovery After Surgery pathway.
The primary outcome measured was surgical site infections as defined by CDC criteria.
Two hundred five patients were reviewed, 111 preintervention and 94 postintervention. Overall surgical site infection rates were 25.2% preintervention vs 26.6% postintervention (p = 0.82). Surgical site infections were subdivided into "superficial" and "deep and organ space" and were 14.4% and 10.8% preintervention vs 14.9% and 11.7% postintervention (p = not significant). Smoking and diabetes mellitus were found to be independently associated with surgical site infections on multivariate analysis, with adjusted odds ratios of 4.32 (95% CI, 1.70-10.94), p = 0.002, and 2.87 (95% CI 1.30-6.34), p = 0.009.
Limitations include the retrospective nature of the study and the small sample size.
There was no change in surgical site infection rates after implementation of the "Colorectal Closure Bundle." Smoking and diabetes mellitus were the only significant risk factors associated with increased surgical site infections. Our infection rates remain high and further change in our perioperative protocol is needed.
As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is ...scarce.
A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded.
Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18-59, 60-69, 70-79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60-69, 70-79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups.
Perioperative mortality with emergency colectomy increases with patients' age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.
Intraoperative administration of dexmedetomidine has shown promise in improving postoperative gastrointestinal function. In the context of colorectal surgery, the results remain inconsistent. This ...review aims to provide a synthesis of studies assessing the effect of dexmedetomidine on postoperative gastrointestinal function in colorectal surgery patients.BACKGROUNDIntraoperative administration of dexmedetomidine has shown promise in improving postoperative gastrointestinal function. In the context of colorectal surgery, the results remain inconsistent. This review aims to provide a synthesis of studies assessing the effect of dexmedetomidine on postoperative gastrointestinal function in colorectal surgery patients.CENTRAL, Emcare, Embase, and MEDLINE were searched up to September 2023. Randomized controlled trials involving adult patients (≥ 18 years) undergoing elective colorectal surgery, comparing dexmedetomidine administration to a control group, and reporting on postoperative gastrointestinal function were included. Non-comparative and emergent procedures were excluded. Primary outcome was time to first flatus or bowel movement, and secondary outcomes included length of stay and time to solid oral intake. Risk of bias was assessed using the Cochrane risk of bias tool for randomized studies.METHODSCENTRAL, Emcare, Embase, and MEDLINE were searched up to September 2023. Randomized controlled trials involving adult patients (≥ 18 years) undergoing elective colorectal surgery, comparing dexmedetomidine administration to a control group, and reporting on postoperative gastrointestinal function were included. Non-comparative and emergent procedures were excluded. Primary outcome was time to first flatus or bowel movement, and secondary outcomes included length of stay and time to solid oral intake. Risk of bias was assessed using the Cochrane risk of bias tool for randomized studies.After screening 1194 citations, eight studies were included. Studies comprised of 570 patients in the dexmedetomidine group (mean age: 65.8 years, 43% female, mean BMI: 22.7 kg/m2) and 556 patients in control group (mean age 70.6 years, 40% female, mean BMI 22.5 kg/m2). Dexmedetomidine administration resulted in a shorter time to flatus (MD -4.55 h, 95% CI: 20.14-8.95, p < 0.005, very low certainty of evidence), a shorter time to first bowel movement (MD -11.9 h, 95% CI: 18.74-5.05, p < 0.005, very low certainty of evidence), a shorter time to solid oral intake (MD -4.34 h, 95% CI: 17.43-11.24, p < 0.005, moderate certainty of evidence), and a shorter length of stay (MD -.06 days, 95% CI: 1.99-0.12, p < 0.05, very low certainty of evidence).RESULTSAfter screening 1194 citations, eight studies were included. Studies comprised of 570 patients in the dexmedetomidine group (mean age: 65.8 years, 43% female, mean BMI: 22.7 kg/m2) and 556 patients in control group (mean age 70.6 years, 40% female, mean BMI 22.5 kg/m2). Dexmedetomidine administration resulted in a shorter time to flatus (MD -4.55 h, 95% CI: 20.14-8.95, p < 0.005, very low certainty of evidence), a shorter time to first bowel movement (MD -11.9 h, 95% CI: 18.74-5.05, p < 0.005, very low certainty of evidence), a shorter time to solid oral intake (MD -4.34 h, 95% CI: 17.43-11.24, p < 0.005, moderate certainty of evidence), and a shorter length of stay (MD -.06 days, 95% CI: 1.99-0.12, p < 0.05, very low certainty of evidence).In adult patients undergoing elective colorectal surgery, intraoperative use of dexmedetomidine results in clinically meaningful improvements in postoperative gastrointestinal function and consequently, shorter length of stay. Therefore, dexmedetomidine may serve as a valuable adjunct in enhancing postoperative recovery of patients following elective colorectal surgery, thereby reducing healthcare utilization, and improving patient outcomes.CONCLUSIONIn adult patients undergoing elective colorectal surgery, intraoperative use of dexmedetomidine results in clinically meaningful improvements in postoperative gastrointestinal function and consequently, shorter length of stay. Therefore, dexmedetomidine may serve as a valuable adjunct in enhancing postoperative recovery of patients following elective colorectal surgery, thereby reducing healthcare utilization, and improving patient outcomes.
Aim
There is significant practice variation with respect to the use of bowel preparation to reduce surgical site infection (SSI) following colon surgery. Although intravenous antibiotics + mechanical ...bowel preparation + oral antibiotics (IVA + MBP + OA) has been shown to be superior to IVA + MBP and IVA, there are insufficient high‐quality data from randomized controlled trails (RCTs) that directly compare these options. This is an important question, because if IVA + OA has similar effectiveness to IVA + MBP + OA, mechanical bowel preparation can be safely omitted, and the associated side effects avoided. The aim of this work is to compare rates of SSI following IVA + OA + MBP (MBP) versus IVA + OA (OA) for elective colon surgery.
Method
This is a multicentre, parallel, two‐arm, noninferiority RCT comparing IVA + OA + MBP versus IVA + OA. The primary outcome is the overall rate of SSI 30 days following surgery. Secondary outcomes are length of stay and 30‐day emergency room visit and readmission rates. The planned sample size is 1062 subjects with four participating high‐volume centres. Overall SSI rates 30 days following surgery between the treatment groups will be compared using a general linear model. Secondary outcomes will be analysed with linear regression for continuous outcomes, logistic regression for binary outcomes and modified Poisson regression for count data.
Conclusion
It is expected that IVA + OA will work similarly to IVA + MBP + OA and that this work will provide definitive evidence showing that MBP is not necessary to reduce SSI. This is highly relevant to both patients and physicians as it will have the potential to significantly change practice and outcomes following colon surgery in Canada and beyond.
Treatment of rectal cancer is ever evolving with the introduction of newer surgical technologies and multimodal treatment approach. The literature evaluating the various surgical treatment options ...with regards to operative and nonoperative outcomes is abundant. This is a comprehensive review focused on oncological outcomes of rectal cancer resection performed robotically or laparoscopically. Based on the current literature available, there is no significant difference in total mesorectal excision completeness, lymph node harvest, positive circumferential resection margin, or proximal resection margin between robotic and laparoscopic approaches for rectal resection. Selection of surgical approach should not be based on pathological outcomes as they are equivalent.
This systematic review and meta-analysis seeks to evaluate the impact of total neoadjuvant therapy (TNT) for rectal cancers on surgical complications and surgical pathology when compared with ...standard long-course chemoradiotherapy (LCRT).
The oncological benefits of TNT are well published in previous meta-analyses, but there is little synthesized information on how it affects surgical outcomes. A recent study has suggested an increase in local recurrence and higher rates of breached total mesorectal excision (TME) plane in TNT patients.
This study conformed to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A search was performed in Medline (via PubMed), Cochrane databases, EMBASE and CINAHL to identify relevant randomized controlled trials (RCTs) comparing outcomes between TNT and LCRT. Meta-analyses of pooled proportions between TNT and LCRT were performed, comparing primary outcomes of surgical mortality, morbidity and all reported complications; surgical-pathology differences, namely mesorectal quality, R0 resection rates, circumferential resection margin positive rates, and sphincter preservation rates. Death and progression of disease during neoadjuvant treatment period was also compared. Risk of bias of RCTs was performed using the Cochrane risk-of-bias tool by 2 independent reviewers.
A total of 3185 patients with rectal cancer from 11 RCTs were included in the analysis: 1607 received TNT and 1578 received LCRT, of which 1422 (TNT arm) and 1391 (LCRT arm) underwent surgical resection with curative intent. There was no significant difference in mortality risk ratio (RR)=0.86, 95% CI: 0.13-5.52, P =0.88, I2 =52% or major complications (RR=1.04, 95% CI: 0.86-1.26, P =0.70, I2 =0%) between TNT and LCRT. There was a significantly higher risk of breached TME in TNT group on pooled analysis (RR=1.49, 95% CI: 1.03-12.16, P =0.03, I2 =0%), and on subgroup analysis there is higher risk of breached TME in those receiving extended duration of neoadjuvant treatment (>17 weeks from start of treatment to surgery) when compared with LCRT (RR=1.61, 95% CI: 1.06-2.44, P =0.03). No difference in R0 resection rates (RR=0.85, 95% CI: 0.66-1.10, P =0.21, I2 =15%), circumferential resection margin positive rates (RR=0.87, 95% CI: 0.65-1.16, P =0.35, I2 =10%) or sphincter preservation rates (RR=1.02, 95% CI: 0.83-1.25, P =0.88, I2 =57%) were observed. There was a significantly lower risk of progression of disease to an unresectable stage during the neoadjuvant treatment period in TNT patients (RR=0.60, 95% CI: 0.39-0.92, P =0.03, I2 =18%). On subgroup analysis, it appears to favor those receiving extended duration of neoadjuvant treatment (RR=0.44, 95% CI: 0.26-0.80, P =0.002), and those receiving induction-type chemotherapy in TNT (RR=0.25, 95% CI: 0.07-0.88, P =0.03).
TNT increases rates of breached TME which can contribute to higher local recurrence rates. TNT, however, improves systemic control by reducing early progression of disease during neoadjuvant treatment period. Further research is warranted to identify patients that will benefit from this strategy.
Colorectal surgery has markedly advanced due to the introduction of laparoscopic and robotic surgery. During the past 20 years, these two modalities have been further enhanced by fluorescence ...imaging.
This article will review the common and novel uses for fluorophores in colorectal surgery, including tissue perfusion for anastomotic creation, ureter identification, lymphatic mapping, and tumor localization.
The versatility of this technology permeates through many aspects of colorectal procedures. The white light spectrum has historically been the only available modality to visualize tissue perfusion, tumor implants, and structures including the ureters and lymph nodes. The ability of the near-infrared spectrum to penetrate biologic tissues allows the identification of these structures with injection of fluorophores. The two most common intravenously utilized fluorophores are methylene blue and indocyanine green. Additionally, novel tumor marker-specific fluorophores are being investigated for purposes of cancer detection.
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