Tan Arulampalam

Screening for colorectal cancer: established and emerging modalities

It has been estimated that >95% of cases of colorectal cancer (CRC) would benefit from curative surgery if diagnosis was made at an early or premalignant polyp stage of disease. Over the past 10 years, most developed nation states have implemented mass population screening programs, which are typically targeted at the older (at-risk) age group (>50–60 years old). Conventional screening largely relies on periodic patient-centric investigation, particularly involving colonoscopy and flexible sigmoidoscopy, or else on the fecal occult blood test. These methods are compromised by either low cost-effectiveness or limited diagnostic accuracy. Advances in the development of diagnostic molecular markers for CRC have yielded an expanding list of potential new screening modalities based on investigations of patient stool (for colonocyte DNA mutations, epigenetic changes or microRNA expression) or blood specimens (for plasma DNA mutations, epigenetic changes, heteroplasmic mitochondrial DNA mutations, leukocyte transcriptome profile, plasma microRNA expression or protein and autoantibody expression). In this Review, we present a critical evaluation of the performance data and relative merits of these various new potential methods. None of these molecular diagnostic methods have yet been evaluated beyond the proof-of-principle and pilot-scale study stage and it could be some years before they replace existing methods for population screening in CRC.

Laparoscopic resection of diverticular fistulae: a 10-year experience.

Objective  Until recently the laparoscopic approach was reserved for uncomplicated diverticular disease. We show that fistulating diverticular disease can be resected safely, with good clinical outcome via a laparoscopic approach.

Incisional hernia rates following laparoscopic colorectal resection

INTRODUCTION In published series with satisfactory follow-up incisional hernia rates following laparotomy vary between 4 and 18%, with up to 75% developing within two years of operation. This therefore represents the commonest complication following open abdominal surgery and a substantial added workload for the colorectal/general surgeon. AIM To prospectively review incisional hernia rates in patients undergoing laparoscopic colorectal resection in a single centre. METHODS All laparoscopic wounds were closed in identical fashion to open closure technique, utilising 0-monofilament, polyglyconate and a mass closure technique, followed by a subcuticular, polyglactin-910 suture for skin closure. All patients were subsequently examined in an outpatient setting by a senior surgeon independent to the original procedure. RESULTS 167 consecutive patients undergoing laparoscopic colorectal resections (94M:73F; median age 68 years) were included. Median incision length for specimen extraction was 6 cm (range 3-11 cm) and patients were followed-up for a median of 36 months (range 24-77 months). Twelve (7%) patients developed an incisional hernia (ten in specimen extraction wounds and two in port-site wounds), ten of whom underwent successful laparoscopic repairs. Of the remaining patients, one remains symptomatic and awaits repair, and one is asymptomatic and unfit for surgery. CONCLUSIONS The well-documented advantages of laparoscopic surgery include reduced hospital stay, early return to activity, decreased analgesic requirements and improved cosmesis. However, the results of this study suggest that incisional hernia rates are not decreased by laparoscopic surgery, although the hernias may be smaller and more amenable to repair by laparoscopic approaches.

Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis

INTRODUCTION Laparoscopic surgery requires a different and sometimes more complex skill set than does open surgery. Shortened working hours, less training times, and patient safety issues necessitates that these skills need to be acquired outside the operating room. Virtual reality simulation in laparoscopic surgery is a growing field, and many studies have been published to determine its effectiveness. AIMS This systematic review and meta-analysis aims to evaluate virtual reality simulation in laparoscopic abdominal surgery in comparison to other simulation models and to no training. METHODS A systematic literature search was carried out until January 2014 in full adherence to PRISMA guidelines. All randomised controlled studies comparing virtual reality training to other models of training or to no training were included. Only studies utilizing objective and validated assessment tools were included. RESULTS Thirty one randomised controlled trials that compare virtual reality training to other models of training or to no training were included. The results of the meta-analysis showed that virtual reality simulation is significantly more effective than video trainers, and at least as good as box trainers. CONCLUSION The use of Proficiency-based VR training, under supervision with prompt instructions and feedback, and the use of haptic feedback, has proven to be the most effective way of delivering the virtual reality training. The incorporation of virtual reality training into surgical training curricula is now necessary. A unified platform of training needs to be established. Further studies to assess the impact on patient outcomes and on hospital costs are necessary. (PROSPERO Registration number: CRD42014010030).

Magnetic resonance-based texture parameters as potential imaging biomarkers for predicting long term survival in locally advanced rectal cancer treated by chemoradiotherapy

The study aimed to investigate whether textural features of rectal cancer on MRI can predict long‐term survival in patients treated with long‐course chemoradiotherapy.

Incisional hernia rate after laparoscopic colorectal resection is reduced with standardisation of specimen extraction.

INTRODUCTION Incisional hernia is a common complication of laparoscopic colorectal surgery. Extraction site may influence the rate of incisional hernias. Major risk factors for the development of incisional hernias include age, diabetes, obesity and smoking status. In this study, we investigated the effect of specimen extraction site on incisional hernia rate. METHODS Two cohorts of patients who underwent laparoscopic colorectal resections in a single centre in 2005 (n=85) and 2009 (n=139) were studied retrospectively. In 2005 all specimens were extracted through transverse muscle cutting incisions. In 2009 all specimens were extracted through midline incisions. Demographic variables, rate of incisional hernias and risk factors for hernia development were compared between the year groups. All patients had been followed up clinically for two years. RESULTS A total of 224 patients (mean age: 67.5 years, standard deviation: 16.35 years) were included in this study. Of these, 85 patients were in the 2005 transverse group and 139 were in the 2009 midline group. The total incisional hernia rate for the series was 8.0% at the two-year follow-up visit. For the 2005 group, the incisional hernia rate was 15.3% (n=13) and for the 2009 group, it was 3.6% (n=5) (p<0.01). The body mass index was higher in patients who developed incisional hernias than in those who did not (p=0.02). CONCLUSIONS The 2005 group had a significantly higher incisional hernia rate than the 2009 group. This is due to the differences in the incision technique and extraction site between the two groups.

Training in laparoscopic colorectal surgery – experience of training in a specialist unit

INTRODUCTION Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproctologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome. PATIENTS AND METHODS Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorectal excision were recorded in oncological procedures. RESULTS Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospital stay was 7 days (range, 2-48 days). There were three conversions. Anastomotic leaks developed in two patients, one requiring a laparotomy. One patient developed small bowel obstruction secondary to a port site hernia, which was repaired laparoscopically. There was one postoperative death. All oncological resection margins were clear with adequate lymphadenectomies. All total mesorectal excisions were Quirke grade III. CONCLUSIONS Adequately trained and supervised trainees may perform major colorectal resections without compromising outcome.

The incidence of incisional hernias following ileostomy reversal in colorectal cancer patients treated with anterior resection

INTRODUCTION The aim of this study was to identify the rate of incisional hernia formation following ileostomy reversal in patients who underwent anterior resection for colorectal cancer. In addition, we aimed to ascertain risk factors for the development of reversal‐site incisional hernias and to record the characteristics of the resultant hernias. MATERIALS AND METHODS Using a prospectively compiled database of colorectal cancer patients who were treated with anterior resection, we identified individuals who had undergone both ileostomy formation and subsequent reversal of their ileostomies from January 2005 to December 2014. Medical records were reviewed to record descriptive patient data about risk factors for hernia formation, operative details and any subsequent operations. Computed tomography reports were reviewed to identify the number, site and characteristics of incisional hernias. RESULTS A total of 121 patients were included in this study; 14.9% (n = 18) developed an incisional hernia at the ileostomy reversal site; 17.4% (n = 21) at a non‐ileostomy site and 6.6% (n = 8) developed both. The reversal‐site hernias were smaller both in width and length compared with the non‐ileostomy‐site hernias. Risk factors for the development of reversal‐site incisional hernias were higher body mass index (BMI), lower age, open surgery, longer reversal time and a history of previous hernias. We did not detect a difference in the size of the incisional hernias that developed in patients with these specific risk factors. CONCLUSIONS Incisional hernias are a significant complication of ileostomy reversal. Further evaluation of the use of prophylactic mesh to reduce the incidence of incisional hernias may be worthwhile.

Positional complications of minimal access surgery, laparoscopic/robotic/transanal surgery

Colorectal surgeons have seen a decade of real advancements in the use of newer techniques and technology to treat diseases of the colon and rectum. Development of better tools, laparoscopic and robotic technologies has enabled surgeons to minimize the incisions, reduce surgical trauma, improved access and articulation with minimal collateral damage. However, all of this does require expertise in advanced minimal access techniques which, in turn requires better training and team work. This article is protected by copyright. All rights reserved.

Survival following rectal cancer surgery: does the age matter?

Abstract Introduction: Information regarding rectal cancer surgery outcomes and survival benefits in the elderly is sparse. Radical rectal surgery can be associated with substantial morbidity and mortality. We investigated age-specific survival for patients undergoing radical rectal surgery to determine outcomes in elderly patients Methods: Over a 10-year period data on all patients who underwent rectal cancer surgery was performed. Patients were grouped according to age and eight other variables including cancer stage (Duke’s/TNM). Data analysed using computer program R. Kaplan–Meier survival curves estimated for age groups and compared using a modified log-rank permutation test. Survival curves fitted using Cox proportional hazard models and hazard ratios obtained Results: About 374 patients underwent surgery. Survival percentages at 1 year by age group are 91.3% for age <50, and 75.5% for age >80. At 5 years these are 87.0% for age <50 and 57.1% for >80. Overall the variation among the survival curves for the age groups is significant (p < .001). The hazard ratio for over the 80+ with the age group <50 as the reference is 4.79 (95% CI: 1.44–15.92) and is significant (p = .011) Conclusion: Overall survival is significantly less in the elderly. There is a striking reduction in survival in >80 year olds in the first post-operative year. This study highlights that care must be taken in deciding whether radical surgery should be offered to those patients and careful consideration is given to allow the best overall survival and quality of life.