Jamil Ahmed

Enhanced recovery after surgery protocols – compliance and variations in practice during routine colorectal surgery

Aim  Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay, the long‐term compliance to such protocols in routine clinical practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice.

Predictors of length of stay in patients having elective colorectal surgery within an enhanced recovery protocol.

BACKGROUND Enhanced recovery after surgery (ERAS) pathways has been shown to minimize the duration of hospital stay. The aim of this study was to identify which factors have the greatest impact at reducing the length of stay within an enhanced recovery programme. METHODS A retrospective case note review of patients undergoing open elective colorectal resections between August 2007 and May 2009 was performed. Data on numerous pre, peri and postoperative variables were collected. Postoperative complications, readmissions, length of stay and fitness for discharge were recorded. Using logistic regression analysis, univariate and multivariate analysis of predictors for a shorter hospital stay was performed. Odd ratios and ninety-five percent confidence intervals were calculated and a p-value of less than 0.05 was significant. RESULTS There were 231 patients, of which 130 were female. Median age was 68 (IQR 56-76) years. Median length of stay was 6 (IQR 5-9) days. On multivariate analysis, ASA grade (OR 2.85 (95%CI 1.17-6.89), p = 0.040), the avoidance of oral opiates in the postoperative period (OR 0.39 (95%CI 0.18-0.84), p = 0.016) and the duration of use of epidurals for postoperative analgesia (OR 0.44 (95%CI 0.12-0.94), p = 0.023) were found to be significant predictors of reduced hospital stay. CONCLUSION Lower ASA grade, use of epidurals and avoidance of regular oral opiates are associated with an earlier discharge in an ERAS programme.

Three-step standardized approach for complete mobilization of the splenic flexure during robotic rectal cancer surgery

The aim of this technical note is to describe a three‐step technique for expeditious and complete mobilization of the splenic flexure (CMSF) during single docking totally robotic rectal cancer surgery.

Robotic versus laparoscopic rectal surgery in high-risk patients

Laparoscopic rectal surgery is associated with a steep learning curve and high conversion rate despite progress in equipment design and consistent practice. The robotic system has shown an advantage over the laparoscopic approach due to stable three‐dimensional views, improved dexterity and better ergonomics. These factors make the robotic approach more favourable for rectal surgery. The aim of this study was to compare the perioperative outcomes of laparoscopic and robotic rectal cancer surgery in high‐risk patients.

Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery

AIM To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery. METHODS A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors. RESULTS Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions. CONCLUSION There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.

Prior experience in laparoscopic rectal surgery can minimise the learning curve for robotic rectal resections: a cumulative sum analysis.

BackgroundThe learning curve for robotic colorectal surgery is ill-defined. This study aimed to investigate the learning curve of experienced laparoscopic rectal surgeons when starting with robotic total mesorectal excision (TME) using cumulative sum (CUSUM) charts.MethodsThis retrospective case series analysed patients who underwent curative and elective laparoscopic or robotic TMEs for rectal cancer performed by two surgeons. The first consecutive robotic TME cases of each surgeon were 1:1 propensity score matched to their laparoscopic TME cases using age, body mass index, American Society of Anesthesiologists grade, T stage (AJCC) and tumour location height. The matched laparoscopic cases defined individual standards for the quality indicators: operating time, R stage, lymph node harvest, length of hospital stay and major complications (Clavien–Dindo grade 3–5). Deviation of more than a quarter of a standard deviation from the mean for the continuous indicators, or exceeding the observed risk for the binary indicators was defined as off-target with an upward inflection in the CUSUM curve.ResultsFrom 2006 to 2015, 384 (294 laparoscopic; 90 robotic) TMEs met the inclusion criteria. Surgeon A performed 206 (70.1%) of the laparoscopic and 43 (47.8%) of the robotic cases. Surgeon B performed 88 (29.9%) of the laparoscopic and 47 (52.2%) of the robotic cases. After matching, no covariate exhibited an absolute standardised mean difference >0.25. For surgeon A, the CUSUM curves showed no apparent learning process compared to his laparoscopic standards. For surgeon B, a learning process for operation time, lymph node harvest and major complications was demonstrated by an initial upward inflection of the CUSUM curves; after 15 cases, all quality indicators were generally on target.ConclusionsFor experienced laparoscopic colorectal surgeons, the formal learning process for robotic TME may be short to reach a similar performance level as obtained in conventional laparoscopy.

Standardized technique for single-docking robotic rectal surgery.

The aim of this technical note is to describe our standardized technique for rectal surgery using a single‐docking totally robotic approach.

Tailored robotic abdominoperineal resection with the da Vinci Xi for a re-growth of rectal tumour after complete clinical response - a video vignette.

Controversy persists as to the optimal surgical technique for abdominoperineal excision of the rectum (APER).(1–3). Extra-levator dissection has been advocated by certain groups who claim to have better R0 resection rates and a reduced incidence of perforation (4–6). However, such a radical approach may result in poorer wound healing, prolonged hospital stay and increased wound morbidity (7). In this operative video we present an abdominoperineal resection using the da Vinci Xi on a 34-year-old lady who had a low rectal adenocarcinoma. This article is protected by copyright. All rights reserved.

Modular approach for single docking robotic colorectal surgery

We have read the article by Priatno and Kim with great interest (1). The article and attached video describe the single docking technique for rectal resection using the da Vinci ® Si system. Robotic rectal surgery has shown steady increase during recent times. With challenging ergonomics of heavy mechanical arm of the robotic Si system, arm collision was often quoted as the main reason for limited adoption. With this in mind, surgeons have tried various other techniques such as hybrid, laparoscopic assisted or double docking as possible solution to this problem (2-4).

Robotic lower anterior resection for a regrowth following complete clinical response - a video vignette

Chemoradiation is increasingly being recognised as an important factor for downstaging rectal cancer before surgery. A proportion of these patients would develop a complete clinical response following neo-adjuvant chemoradiation (1). This article is protected by copyright. All rights reserved.