New normal Loon, Yu‐Ting; Clermonts, Stefan; Zimmerman, David
Colorectal disease,
August 2021, Letnik:
23, Številka:
8
Journal Article
Recenzirano
We read with great interest the recent study by Mirza et al. We would like to applaud the authors for their extensive analysis of the results of 150 consecutive Hartmann's reversal (HR) procedures in ...two academic tertiary referral centers between 2010-2019. In a study group with majority of open index cases (93.3%), laparoscopic HR (LHR) was attempted in 22% of the cases with 42% conversion rate. They conclude that HR comes with substantial risk of morbidity and that laparoscopic approach may decrease morbidity in selected patients but have high conversion rates. However, we would like to highlight some important nuances. There are many reports stating the positive effects of LHR with less morbidity and mortality rates compared to open HR with great advantages in perioperative outcomes: less blood loss, shorter length of hospital stay and fewer overall postoperative complications such as ileus or surgical site infections. We believe that the use of laparoscopic or minimally invasive approach is underutilized in not only this but many other HR studies.
Background
Primary anastomosis (PA) in left-sided colorectal cancer (CRC) surgery in elderly patients is disputed. The aim of our study was to evaluate the differences in postoperative outcomes after ...left-sided CRC surgery in elderly patients in The Netherlands, comparing patients with PA and those who underwent end-ostomy (EO).
Method
Patients aged ≥ 75 years with stage I–III left-sided CRC, diagnosed and surgically treated in 2015–2017 were selected from the Netherlands Cancer Registry (
n
= 3286). Postoperative outcomes, short-term (30-, 60-, and 90-day) mortality and 3-year overall and relative survival were analyzed, stratified by surgical resection with PA versus EO. Propensity score matching (PSM) and multivariable logistic regression analysis were conducted.
Results
Patients with higher age, higher American Society of Anesthesiologists classification and higher tumor stage, a perforation, ileus or tumor located in the proximal rectum, and after open or converted surgery were more likely to receive EO. No difference in anastomotic leakage was seen in PA patients with or without defunctioning stoma (6.2% vs. 7.0%,
p
= 0.680). Postoperative hospital stay was longer (7.0 vs. 6.0 days,
p
< 0.0001) and more often prolonged (19% vs. 13%,
p
= 0.03) in EO patients. Sixty-day mortality (2.9% vs. 6.4%,
p
< 0.0001), 90-day mortality (3.4% vs. 7.7%,
p
< 0.0001), and crude 3-year survival (81.2% vs. 58.7%,
p
< 0.0001) were significantly higher in EO patients, remaining significant after multivariable and PSM analysis.
Conclusion
There are significant differences between elderly patients after left-sided CRC surgery with PA versus EO in terms of postoperative length of stay, short-term survival, 3-year overall survival, and relative survival at disadvantage of EO patients. This information could be important for decision making regarding surgical treatment in the elderly.
Background
Transanal minimally invasive surgery (TAMIS) is considered the successor of transanal endoscopic microsurgery (TEMS). It makes use of more readily available laparoscopic instruments and ...single-port access platforms with similar perioperative, clinical and oncological outcomes. Little is known about quality of life (QoL) outcomes after the use of TAMIS. The aim of this study was to assess QoL after TAMIS in our patients and compare this with QoL in the healthy Dutch population.
Methods
All patients undergoing TAMIS for selected rectal neoplasms between October 2011 and March 2014 were included in this analysis. Patients were studied for a minimal period of 24 months. QoL outcomes were measured using the Short-Form 36 Health Survey (SF-36) questionnaire; faecal continence was measured using the Faecal Incontinence Severity Index questionnaire. Patient reported outcomes were compared to case-matched healthy Dutch control subjects.
We hypothesise that undergoing TAMIS will subsequently result in a decreased quality of life in patients compared to healthy individuals.
Results
Thirty-seven patients (m:f = 17:20, median 67 years) were included in the current analysis. In four patients (10.8%), postoperative complications occurred. The median follow-up was 36 (range 21–47) months. Postoperative QoL scores are similar comparable to those reported by Dutch healthy controls. Patients reported a statistically significant better QoL score in the ‘bodily pain’ domain when compared to the controls (81.8 vs. 74.1 points) (
p
= 0.01). Significant worse QoL scores for the ‘social functioning’ domain were reported by patients after TAMIS (84.4 vs. 100 points) (
p
= 0.03).
Conclusion
TAMIS seems to be a safe technique with postoperative QoL scores similar to that of healthy case matched controls in 3-year follow-up. There seems to be no association between faecal incontinence and reported QoL. Negative effects of TAMIS on social functioning of patients should not be underestimated and should be discussed during preoperative counselling.
Background
There is no consensus as to the effects of epidural analgesia on postoperative outcomes after laparoscopy in the context of the Enhanced Recovery Programs. The aim of this study was to ...evaluate the effects of epidural analgesia on postoperative outcomes after elective laparoscopic sigmoidectomy.
Methods
The use of epidural analgesia was discontinued in elective laparoscopic sigmoidectomy and substituted by the perioperative administration of systemic lidocaine. Data from patients undergoing elective laparoscopic sigmoidectomy between January 2014 and September 2016 was prospectively analysed. Patients with epidural analgesia were compared with patients without, in analgesics administrated postoperatively, length of stay, day of first defecation and mobilisation, and complication and reoperation rates.
Results
A total of 160 patients (male 85; female 75), median age 68 (30–92 years), were included. The groups consisted of 80 patients each. Mean length of stay (5.6 vs. 7.2 days,
p
= 0.03) and day of first mobilisation (mean 1.2 vs. 1.6 days,
p
= 0.004) were significantly shorter in the group without epidural analgesia. Reoperation rate (7.5 vs. 2.5%) was not statistically different. Complication rate was significantly lower (12.5 vs. 30%,
p
= 0.007) in the group without epidural. Day of first defecation was shorter in the epidural group (1.4 vs. 1.7 days,
p
= 0.04). Mean amount of analgesics administrated was not statistically different between groups, except for metamizole, that was administrated more in the group without epidural.
Conclusions
Epidural analgesia did not offer benefits on postoperative analgesia or outcomes after elective laparoscopic sigmoidectomy, causing longer length of stay, later mobilisation and higher complication rate.
Background
Considerable morbidity (10–14%) and even mortality (4–30%) have been reported after reversal of intestinal continuity following Hartmann’s procedure. Feasibility of and advantages in ...reducing peri- and postoperative morbidity by utilizing single-port techniques through the colostomy site have been suggested before in small case series. The purpose of the present prospective observational study is to evaluate the outcomes of reversal of intestinal continuity using single-port access in a relatively large consecutive cohort.
Methods
All consecutive patients undergoing single-port reversal of left-sided colostomy (SPRLC) between November 2012 and 2018 were included in the present study. Primary outcome was 30-day postoperative complication rate. Secondary outcomes were postoperative length of stay, single-port success rate, and surgical details like duration and conversion rates.
Results
Of 85 procedures, 69.4% were without postoperative complications. No postoperative mortality was encountered. Superficial site infection is the most frequent complication and occurred in 22.4%, major complications classified as Clavien–Dindo grade 3 or above in 9.4% and anastomotic leakage in 3.5%. Median length of stay was 3.0 days (1–69), single-port success rate was 64.7%, and 15.3% was converted to an open procedure.
Conclusion
This study confirms the safety, feasibility, and the advantages of SPRLC. In centers with adequate laparoscopic experienced surgeons, this technique should be considered as a serious and attractive alternative to restore intestinal continuity in patients with left-sided end colostomy, especially in patients after open index surgery. More research must be done in a multicenter setting to evaluate the use and standardization of single-port technique in reversal of intestinal continuity procedures.
Background
Complications after restoration of intestinal continuity (RIC) following Hartmann’s procedure occur frequently and are often serious. These complications result in a reported morbidity of ...4–30 % and a reported mortality of 10–14 %. Reducing the amount of surgical trauma accompanying abdominal access seems an attractive tool to reduce perioperative morbidity. This possibility is offered by single-port Hartmann’s reversal (SPHR) through the colostomy site.
Methods
The purpose of the present prospective study was to compare outcome of SPHR to a retrospectively collected historical control group of conventional open Hartmann’s reversal (OHR). All patients undergoing RIC between January 1, 2009, and January 1, 2014, were included in the present study. Operation time, morbidity and hospital stay were assessed. Postoperative surgical results of SPHR and OHR were the main outcome of the study.
Results
During the study period, 41 patients (M/F = 23:18; median age 58 (26–85) years) were included in the present study. Sixteen patients underwent OHR; 25 patients underwent SPHR. No mortality was observed in the present series. Median operation time was similar between groups 184 (29–377) vs. 153.5 (73–332) min. Hospital stay was significantly shorter in the SPHR group 16 (4–74) vs. 4 (1–34) days,
p
< 0.05. The number of complications was significantly lower in the SPHR group (33 vs. 10,
p
< 0.05); furthermore, significantly less patients had severe complications (Clavien–Dindo III or higher) in the SPHR group (7/33 vs. 1/10). Less wound-related complications occurred in the SPHR group (12 vs. 5,
p
< 0.05).
Conclusion
This study confirms recent findings in the literature regarding the safety and feasibility of SPHR. SPHR seems to be an attractive alternative to OHR.
Aim: Stoma reversal in patients with concomitant abdominal wall defects can be cumbersome with the risk of many postoperative complications. Present study was conducted to evaluate feasibility and ...safety of single port restoration of left-sided colostomy in patients with concomitant incisional hernia. Method: All patients with concomitant incisional hernia undergoing single-port reversal of left-sided colostomy (SPRLC) between 2012 and 2020 were included. Primary outcomes were surgical success rate and 30-day postoperative complication rate. Secondary outcome was subsequent hernia repair after successful stoma reversal. Results: Twelve patients were included for analysis. Single-port reversal was possible in five patients, conversion to open surgery was needed in one patient and conversion to multiport laparoscopy in six patients. There was no postoperative mortality, reoperations or anastomotic leakages. Seven patients (58%) encountered no postoperative complications, surgical site infection occurred in four patients, pneumonia in one patient. Median postoperative stay was 4 (range; 3-12) days. Two patients pursued hernia repair after successful stoma reversal. Conclusion: SPRLC is feasible and can be considered as an attractive alternative to open approach in patients with a colostomy and concomitant incisional hernia. It can be considered as a step-wise approach for future abdominal wall repair.
Aim
Cohort data suggest that anastomotic leak occurs after 8% of right colectomies causing significant morbidity and mortality. Patient selection, intra‐operative factors, and technical variation all ...contribute to risk of leak. The EAGLE study will assess whether implementation of the European Society of Coloproctology (ESCP) Safe Anastomosis Intervention reduces anastomotic leak following right colectomy.
Methods
An international, multi‐centre, cluster randomised trial will be undertaken with hospitals as clusters. Hospitals will be recruited in a number of distinct phases, with each phase following the same research plan, in which clusters are randomised to one of three, staggered (dog‐leg) schedules for implementation of the Safe Anastomosis Intervention.
Results
Results from different phases will be meta‐analysed. The intervention is a three‐component behavioural change programme for surgeons, anaesthetists and operating room staff, supported by an online learning environment. All colorectal surgical units around the world will be eligible. Adults undergoing elective or emergency right colectomy or ileocaecal resection, by any approach and for any indication will be included. The primary outcome is 30‐day anastomotic leak rate, defined as clinical or radiologically‐detected leak or intra‐abdominal or pelvic collection. Assuming hospitals provide data for an average of 10 patients per two month recruitment period, 333 clusters (4440 patients in total) will allow for detection of an absolute risk reduction of anastomotic leak from 8.1% to 5.6% (relative risk reduction 30%). This protocol adheres to Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT).
Discussion
The protocol describes the methods for an evaluation of a hospital‐level, education‐based quality improvement intervention targeted to reduce the life‐threatening surgical complication of anastomotic leak.
The ileostomy pathway, introduced in 2011, has proved to be successful in eliminating hospital readmissions for high-output ileostomy or dehydration in the following period of 7 months in a single ...institution. However, it is unclear whether this short-term success, immediately after the initiation of the program, can be sustainable in the long term.
The aim of this study was to assess the efficacy and the durability of the ileostomy pathway in reducing readmissions for dehydration over a longer period of time.
This was a retrospective review of the patients who entered into the ileostomy pathway, since its introduction on March 1, 2011, until January 31, 2015.
This study was conducted at a tertiary academic center.
Patients undergoing colorectal surgery with the creation of a new end or loop ileostomy were included.
The long-term sustainability of the ileostomy pathway was assessed.
The primary end point was readmission within 30 days after discharge for a high-output ileostomy or dehydration.
A total of 393 patients (male n = 195, female n = 198, median age 52 (18-87) years) were included: 161 prepathway and 232 on-pathway. Overall 30-day postdischarge readmission rates decreased from 35.4% to 25.9% (p = 0.04). Readmissions due to high output and/or dehydration dropped from 15.5% to 3.9% (p < 0.001). Readmissions due to small-bowel obstructions dropped from 9.9% to 4.3%, (p = 0.03).
The possible limitations of the study included a nonrandomized comparison of the patient groups and those patients who were possibly admitted to different institutions.
The present ileostomy pathway decreases readmissions for high-output ileostomy and dehydration in patients with new ileostomies and is durable in the long term. See Video Abstract at http://links.lww.com/DCR/B233. EFICACIA DE VÍA DE ILEOSTOMÍA PARA REDUCIR LOS REINGRESOS POR DESHIDRATACIÓN: ¿RESISTE LA PRUEBA DEL TIEMPO?: La vía de ileostomía, introducida en 2011, ha demostrado ser exitosa en la eliminación de reingresos hospitalarios por ileostomía de alto rendimiento o deshidratación, por un período de 7 meses, en una sola institución. Sin embargo, no se ha aclarado si el éxito es a corto plazo, inmediatamente después del inicio del programa, y de que pueda ser sostenible a largo plazo.El objetivo de este estudio fue evaluar la eficacia y la durabilidad de la vía de ileostomía, para disminuir los reingresos por deshidratación, durante un período de tiempo más largo.Esta fue una revisión retrospectiva de pacientes que ingresaron a la vía de ileostomía, desde su introducción el 1 de marzo de 2011 hasta el 31 de enero de 2015.Este estudio se realizó en un centro académico terciario.Se incluyeron pacientes sometidos a cirugía colorrectal con la creación de una nueva ileostomía de extremo o asa.Evaluar la sostenibilidad de la vía de ileostomía a largo plazo.El punto final primario fue el reingreso dentro de los 30 días posteriores al alta, por una ileostomía de alto gasto o deshidratación.Se incluyeron un total de 393 pacientes (hombres n = 195, mujeres n = 198, edad media 52 18-87 años), 161 antes de la vía y 232 en la vía. En general, las tasas de reingreso después del alta a 30 días, disminuyeron de 35.4% a 25.9% (p = 0.04). Los reingresos por alto rendimiento y / o deshidratación, disminuyeron del 15.5% al 3.9% (p < 0.001). Los reingresos debidos a obstrucciones del intestino delgado, disminuyeron del 9.9% al 4.3% (p = 0.03).Las posibles limitaciones del estudio incluyeron una comparación no aleatoria de los grupos de pacientes, y de aquellos pacientes que posiblemente fueron admitidos en diferentes instituciones.La vía de ileostomía disminuye los reingresos por ileostomía de alto gasto y deshidratación, en nuevos pacientes con ileostomía, y es duradera a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B233.
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