Samson Tou

Effect of preoperative two‐dimensional animation information on perioperative anxiety and knowledge retention in patients undergoing bowel surgery: a randomized pilot study

The use of multimedia information provided preoperatively can potentially reduce anxiety in patients and improve the hospital experience. However, the use of two‐dimensional (2D) animation (cartoon) to provide information to patients undergoing colorectal surgery has not been investigated. This study investigated the effect of preoperative 2D information on anxiety and knowledge retention in patients undergoing bowel surgery.

Prognostic significance of lymph node yield after long-course preoperative radiotherapy in patients with rectal cancer: a systematic review.

Aim  A literature review was performed to elucidate whether long‐course preoperative radiotherapy for patients with rectal cancer affects lymph node yield, and whether this influences prognosis.

Day-case closure of ileostomy: feasible, safe and efficient

Over 5000 loop ileostomy closures were performed in the UK in 2013 with a median inpatient stay of 5 days. Previously we have successfully implemented a 23‐h protocol for loop ileostomy closure which was modified for same‐day discharge. We present our early experience of day‐case loop ileostomy closure.

Structured training in robotic colorectal surgery.

Over the last decade there have been major changes in surgery. Robotic-assisted surgery, which can trace its origins back to 1985, is the latest breakthrough. Although it was initially used in neurosurgery, urology is becoming a fast adopter of the technology. Currently there are approximately 2100 robots in the United States and 520 in Europe, including 45 in the United Kingdom. The technology is being slowly adopted in colorectal surgery. The main application of robots in colorectal procedures is in rectal surgery, owing to the confined operative field; however, increasingly more complex operations are being performed, including pelvic exenteration. There is currently no formal component for robotic surgery in the training curriculum in Europe and North America. In the United States a combined programme from the American Society of Colon and Rectal Surgeons and Intuitive Surgical sponsors residents to attend a 3-day cadaver/porcine laboratory for robotic training; although most robotic surgery skills are acquired only after surgeons have finished their residency and fellowship training. The Halsted approach ‘see one, do one, teach one’ has been slowly replaced by more formal structured learning. This has been exemplified by the introduction of laparoscopic surgery. Most of the learning takes place outside the operating theatre environment with the use of didactic teaching, acquiring skills through training tools, virtual reality, animal models and cadavers, with emphasis on assessment and continuous auditing outcomes for surgeons. Can we adopt the laparoscopic surgery model of training and assessment? What would be the ideal way of learning a new technique? Can we learn from other specialties, in particular urology, as they are the main users of robotic surgery worldwide? Should the professional bodies take a more active role in regulating training and auditing outcome data? There are currently few curricula designed to introduce formal training and assessment in robotic surgery. The fundamental skills of robotic surgery (FSRS) is a virtual reality-based curriculum designed by a group of urologists in North America and the United Kingdom. The curriculum focuses on four basic areas required in roboticassisted surgery including orientation, motor skills, basic surgical skills and intermediate surgical skills. A structured fellowship programme was introduced by the European Robotic Urology Society (ERUS). This 3-month fellowship includes theoretical sessions, skills training (dry and wet laboratories), real-case observation in training centres, bedside assistance and mentored training at the console. More recently, owing to the increasing need for training in and assessment of robotic colorectal surgery, the European Academy of Robotic Colorectal Surgery (EARCS) was founded in June 2014; to date this is a single coordination unit with 10 participating European centres. The programme is open to consultant colorectal surgeons who have good experience in either open or laparoscopic colorectal surgery, with access to a robotic system as supported by their local hospitals. The training involves familiarization with the robotic system, attending the animal and cadaveric courses, case observations and hands-on training (in-reach and out-reach) using a modular approach, with the aim of performing cases solo. There will be a sign-off procedure using an objective competency assessment before solo practice. The curriculum emphasizes specimen-orientated surgery, i.e. in rectal surgery. pathologists would assess the total mesorectal excision (TME) grade so as to allow surgeons to focus on embryological plane dissection which, in effect, translates to good surgical outcomes. Robotic surgery could be a potential solution in the dissection in the pelvis, in particular in male patients and patients with a high body mass index, due to its three-dimensional vision and ‘wristed instruments’. However, the true benefits of robotic surgery will need to be assessed when the results of ongoing trials are available. Other limitations of its use in colorectal surgery are the availability of the systems and the associated cost. In the United Kingdom, NHS England is currently appraising the use of robots in different specialties and will be interested to find out the verdict for colorectal surgery. We do not know whether robotic surgery will stay or not, but training in minimally invasive surgery has certainly revolutionized the traditional surgical apprenticeship and the emphasis on team training and communication.

A randomized double-blind clinical trial of a continuous 96-hour levobupivacaine infiltration after open or laparoscopic colorectal surgery for postoperative pain management--including clinically important changes in protein binding.

Background: Continuous local anesthetic infiltration has been used for pain management after open colorectal surgery. However, its application to patients undergoing laparoscopic colorectal surgery has not been examined. The aim of this prospective, randomized, double-blind, placebo-controlled clinical trial was to study the use of a commercial infiltration device in patients undergoing open or laparoscopic colorectal surgery, along with plasma concentrations of levobupivacaine, its acute-phase binding protein (alpha-1 acid glycoprotein, AAG), and the stress marker, cortisol. Methods: Eligible patients were randomized (2:1) to receive a continuous infiltration of either levobupivacaine or placebo using a commercial device (ON-Q PainBuster) inserted in the preperitoneal layer at the end of surgery. Blood was sampled for determination of levobupivacaine and AAG and cortisol concentrations. Other outcomes measured were pain scores, morbidity and mortality, time to bowel movement, mobilization, and length of hospitalization. Results: In patients having open surgery, the levobupivacaine treatment showed a trend toward reduced total opioid consumption. No patients reported adverse effects attributable to levobupivacaine, despite 11 patients having concentrations at some time(s) during the 96-hour infiltration of up to 5.5 mg/L exceeding a putative toxicity threshold of 2.7 mg/L. AAG concentrations measured postsurgery increased by a mean of 55% (P < 0.001) at 48 hours. Cortisol concentrations also increased significantly by a mean of 191% at 1 hour. Conclusions: Continuous local anesthetic infiltration may be more beneficial in open surgery. The threshold for adverse effects from highly bound local anesthetic drugs established in healthy volunteers is of limited usefulness in clinical scenarios in which AAG concentration increases in response to surgical stress. Hence, there is scope to adopt higher doses to enhance therapeutic benefit.

The bowel cancer awareness campaign ‘Be Clear on Cancer’: sustained increased pressure on resources and over-accessed by higher social grades with no increase in cancer detected

To evaluate the impact of the national ‘Be Clear on Cancer’ bowel cancer reminder campaign on service and diagnosis at a single UK institution. Secondly, to evaluate the socio‐economic background of patients referred before and after the reminder campaign compared with the regional demographic.

Less is more: re-evaluating systematic reviews

This year marks the 25th anniversary of the Cochrane Collaboration. What started in 1993 with an initial group of 77 people from nine countries had generously increased to more than 31 000 contributors from over 120 countries by 2015 [1]. While there are recognised benefits of Cochrane systematic reviews (SRs) over nonCochrane SRs, for examples, superior completeness of reporting and stricter inclusion criteria (often randomised trials only), there are unfortunately relatively fewer Cochrane reviews as a percentage of total as the years go by (20% 2004, 15% 2014) as the absolute volume of SRs in MEDLINE continues to expand (annual publication rate: 2500 in 2004, 8000 in 2014) [2]. Given this continued expansion of studies some of higher quality than others, there has been a move recently to increase value in biomedical research and reduce unnecessary duplication, with a series of recommendations directed at various stakeholders [3]. Many journals, often as part of their author guidelines, recommend the inclusion of a PRISMA checklist and flow diagram. There have been significant discussions on registration of review protocols with PROSPERO and authors suggested that journal editors could mandate what is now still a voluntary registration process [4]. This is relevant because the lion’s share of authors are not aware of PRISMA and/or PROSPERO. Data from 2014 showed that of a sample of 300 SRs analysed only 29% mentioned a reporting guideline (i.e. PRISMA), 16% made their protocols publicly available and 4% registered their protocols with PROSPERO [2]. It is clear that further work still needs to be done to increase these poor rates of guideline reporting and protocol registration. Within the colorectal domain there are two good recent examples of topics that have arguably received more than their fair share of duplication: prophylactic mesh placement to prevent parastomal herniation and laparoscopic lavage (LL) vs colonic resection (CR) in acute diverticulitis. At the time of Nepogodiev’s correspondence [4] the number of recent meta-analyses (MAs) (n = 7) on parastomal hernia prevention were fewer than the number of includable randomised studies (n = 12) and the conclusions of these MAs have essentially been consistent. On the other hand, LL has not been so fortunate as the number of recent MAs (n = 6) now doubles the number of includable randomised studies (n = 3) and the conclusions are contradictory leaving the reader with continued uncertainty and a sense of bewilderment [5,6]. While conclusions in surgical meta-evidence have previously been found to be more heterogeneous than their medical counterparts [7,8], this is particularly puzzling given that all six MAs cite the same three limited number of randomised controlled trials (RCTs): DILALA, LADIES (LOLA) and SCANDIV trials [9–12]. The latest 2018 meta-analysis by Penna et al. [13] is arguably different because it adopted less stringent inclusion criteria and therefore also included four comparative studies. The pooled data of the seven studies, including 589 patients of whom 85% had Hinchey III diverticulitis, showed that LL was associated with a significantly increased risk of peritonitis after the primary surgery, intraabdominal abscesses and the need for emergency surgery between > 30 days to one year as compared to CR. There was no statistical difference in mortality between LL and CR in the short or long term. In a subset analysis of the three RCTs there was also an increased risk of intraabdominal abscesses though the risk of peritonitis was no longer significant as compared to the pooled data. To put this in perspective with previous MAs, in some ways these results are similar where LL possibly has some short-term disadvantages (i.e. increased abscesses, increased reintervention). Importantly, while this analysis reported higher rates of emergency surgery between > 30 days to 1 year in the LL group, some previous MAs have reported decreased reoperations at 12 months. Unfortunately, the authors do not explicitly discuss the rationale for the difference in their study inclusion criteria though this could have been part of their PRISMA-P checklist submitted to the journal. Nor are the differences or similarities in their results put into context with the previous five MAs. Rather, the less informed reader is left to figure this all out on his or her own and this is not a simple task. Certainly, there must be more that we can do as a research community and Journal editors. We wonder whether it is time for the International Committee of Medical Journal Editors (ICMJE) to intervene. Over ten years ago the ICMJE issued a statement on mandatory registration of clinical trials in a public trials registry such as clinicaltrials.gov prior to patient enrolment as a condition for publication. If the ICMJE decide to issue a similar statement for SRs and MAs that would make registration of related protocols with a public registry such as PROSPERO mandatory, perhaps this requirement would help limit duplicate publications. The situation may also call for something deeper in the ICMJE guidelines that require authors of MAs and SRs to provide an extra layer of justification for each subsequent review following publication of the original MA or SR on the subject. Moher [14] previously addressed this issue at the SR protocol level in 2013, with potential for incorporation of this justification into

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement.

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular ‘extra‐levator APE’ (ELAPE).

Functional outcomes after low anterior resection: an important consideration

There is an emphasis in recent surgical publications on the functional results after a low anterior resection. More new treatments are now available, many with the aim to improve functional outcomes and improve quality of life for patients. As Professor Nicholls highlighted in his Editorial, rectal cancer treatment has evolved rapidly over the last 30 years [1]. Advances in stapling technology, neoadjuvant therapy, standardisation of TME surgery are allowing more sphincter-preserving rectal surgery to be performed. However after a low anterior resection, it is not uncommon for patients to report impaired bowel functions, and this has been shown to correlate with poor quality of life [2]. Incontinence has been thought to be synonymous with poor bowel function. Other symptoms including urgency and frequency are also important to be recognised in the Low Anterior Resection Syndrome (LARS). Thanks to Professor Laurberg and his team, a simple tool has been developed to measure bowel functions after restorative low anterior resection – the LARS score [3]. Risk factors associated with worsening LARS score include neoadjuvant therapy, female gender, age (< 65), total mesorectal excision (vs. partial) and anastomotic leakage [4]. In this issue of Colorectal Disease, Jimenez-Rodriguez and co-workers from Spain had investigated whether the interval from cancer resection to ileostomy closure was a risk factor for LARS [5]. This is an important piece of work, as many patients may not have had their stoma reversed for some time after their cancer resection. In a recent UK bowel cancer audit data, over 80% of patients had stoma formation during rectal cancer resection, and only half of them had their stoma reversed at 18 months [6]. The delayed closure of stoma is likely to be multi-factorial including the use of adjuvant therapy, postoperative complications and hospital capacity issues. Formation of a stoma may result in diversion colitis, and the consequence of disuse bowel may lead to irreversible colon and rectal atrophy [7]. In this multivariate analysis of a cohort of 150 patients, our Spanish colleagues did not find any correlation between delayed closure of ileostomy and LARS. Many of their patients had upper rectal cancer, and this may explain the lower rate of ileostomy used. Also, the questionnaires were completed in slightly different time frames between the no stoma group and the ileostomy group. With this in mind, it would be interesting to see if observations from this study are reproducible. Sixty percent of the procedures were performed using an open approach, and the remainder were achieved by laparoscopic or robotic surgery. The use of minimally invasive techniques may allow better visualisation in the pelvis, in the hope that it will allow better preservation of the autonomic nerves and bowel function. The current study did not find any association between surgical approach and LARS, likely due to the study’s small sample size. The debate about the best approach for rectal cancer is still ongoing. Previous research in this area seldom used a standardised bowel functional outcomes as end point measurement. It may be worth adding this component to future trials. The principle of rectal cancer management is to minimise surgical risk, avoid local recurrence and to achieve good functional outcomes. It is often the latter that gets less attention in our decision making during multidisciplinary team (MDT) discussion. It is time to devote more effort to ensure our patients get a better quality of life after rectal cancer treatment. The collaboration between the Danish and the UK LARS groups has recently developed an online tool to predict bowel dysfunction following restorative rectal cancer resection the Preoperative LARS (POLARS) score [8]. This tool may help to formulate a patient-centred treatment plan during MDT and clinic discussion. While every effort needs to be made to improve the oncological outcomes of rectal cancer surgery, regardless of surgical techniques used, functional outcomes and quality of life of our patients cannot be ignored. Therefore, clinicians should endeavour to offer a true end-to-end solution for restorative low anterior resection.

The final twist: the use of a wound protector in reducing an extracorporeal anastomosis - a video vignette.

1 Buess G, Theiss R, Hutterer F et al. Transanal endoscopic surgery of the rectum-testing a new method in animal experiments. Leber Magen Darm 1983; 13: 73–7. 2 van den Boezem PB, Kruyt PM, Stommel MW, Tobon Morales R, Cuesta MA, Sietses C. Transanal single-port surgery for the resection of large polyps. Dig Surg 2011; 28: 412–6. 3 Lacy AM, Tasende MM, Delgado S et al. Transanal total mesorectal excision for rectal cancer: outcomes of 140 patients. J Am Coll Surg 2015; 221: 415–23.