Is colorectal surgery beyond the age of 80 still feasible with acceptable mortality? An analysis of the predictive value of CR-POSSUM and life expectancy after hospital discharge

AIM

Increased morbidity and mortality could mitigate the positive effect of surgery in elderly patients undergoing colorectal resections. This retrospective study aims to describe early morbidity and mortality together with long-term survival in octogenarians and nonagenarians undergoing colorectal surgery. Predictors for in-hospital mortality are identified. The predictive value of CR-POSSUM is assessed.

METHOD

Data on consecutive patients 80 years old or more undergoing a colorectal resection in our centre from 2004 until 2010 were analysed.

RESULTS

Some 286 patients [median age 84 years; interquartile range (IQR) 81.6-86.1; 133 men, 47%] underwent a colorectal resection. Median follow-up was 32 months (IQR 14.5-51.2). Two hundred and fifty-eight patients (90%) were operated on for malignancy. Only 64 patients (22.4%) underwent a laparoscopic procedure. Overall median hospital stay was 12 days (IQR 9.0-20.0) and in-hospital mortality was 9.4%. Seventy-six per cent (n = 170) of patients could return home after discharge. The 1-year survival rate was 78.6% (95% CI 73.8-82.7). Median CR-POSSUM for in-hospital mortality was 12.6% (IQR 11.9-21.0). The concordance probability estimate was 0.668 (95% CI 0.609-0.728), reflecting a moderate predictive capacity of CR-POSSUM. Once patients had been discharged from hospital, life expectancy was similar to that of the Belgian general population.

CONCLUSION

Colorectal surgery in octogenarians and nonagenarians resulted in a considerable in-hospital mortality of about 9%. One-year mortality added an additional 12%, which is in concordance with the overall life expectancy at that age.

ESMO consensus guidelines for the management of patients with metastatic colorectal cancer

Colorectal cancer (CRC) is one of the most common malignancies in Western countries. Over the last 20 years, and the last decade in particular, the clinical outcome for patients with metastatic CRC (mCRC) has improved greatly due not only to an increase in the number of patients being referred for and undergoing surgical resection of their localised metastatic disease but also to a more strategic approach to the delivery of systemic therapy and an expansion in the use of ablative techniques. This reflects the increase in the number of patients that are being managed within a multidisciplinary team environment and specialist cancer centres, and the emergence over the same time period not only of improved imaging techniques but also prognostic and predictive molecular markers. Treatment decisions for patients with mCRC must be evidence-based. Thus, these ESMO consensus guidelines have been developed based on the current available evidence to provide a series of evidence-based recommendations to assist in the treatment and management of patients with mCRC in this rapidly evolving treatment setting.

Modified side-to-side isoperistaltic strictureplasty over the ileocaecal valve for the surgical treatment of terminal ileal Crohn's disease: the ultimate bowel sparing technique?

AIM

The study describes the technique of a modified side-to-side isoperistaltic strictureplasty over the ileocaecal valve.

METHOD

The technical details of a modified side-to-side isoperistaltic strictureplasty of the terminal ileum for stricturing Crohn's disease is described including Figs. 1 and 2 and a video illustration (Video S1).

RESULTS

Between November 2010 and December 2015, 36 patients underwent a side-to-side isoperistaltic strictureplasty of the (neo-)terminal ileum (men 14/36; median age 35 years [interquartile range (IQR) 26-51 years]). Thirty were operated by either multiport or single port laparoscopy. The median length of hospital stay was 9 (IQR 8-11) days. Anastomotic leakage occurred in two patients both in the first five cases. In both the anastomosis could be rescued by additional suturing. After a median follow-up of 18.9 (IQR 7.0-36.0) months, 14 patients had developed clinical recurrence and one had a surgical recurrence at 63 months.

CONCLUSION

A modified side-to-side isoperistaltic strictureplasty is a feasible and safe technique, rendering maximal bowel sparing surgery possible.

Consensus on Recording Deep Endometriosis Surgery: the CORDES statement

STUDY QUESTION

Which essential items should be recorded before, during and after endometriosis surgery and in clinical outcome based surgical trials in patients with deep endometriosis (DE)?

SUMMARY ANSWER

A DE surgical sheet (DESS) was developed for standardized reporting of the surgical treatment of DE and an international expert consensus proposal on relevant items that should be recorded in surgical outcome trials in women with DE.

WHAT IS KNOWN ALREADY

Surgery is an important treatment for symptomatic DE. So far, data have been reported in such a way that comparison of different surgical techniques is impossible. Therefore, we present an international expert proposal for standardized reporting of surgical treatment and surgical outcome trials in women with DE.

STUDY DESIGN, SIZE, DURATION

International expert consensus based on a systematic review of literature.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Taking into account recommendations from Consolidated Standards of Reporting Trials (CONSORT), the Innovation Development Exploration Assessment and Long-term Study (IDEAL), the Initiative on Methods, Measurement and Pain Assessment in Clinical trials (IMMPACT) and the World Endometriosis Research Foundation Phenome and Biobanking Harmonisation Project (WERF EPHect), a systematic literature review on surgical treatment of DE was performed and resulted in a proposal for standardized reporting, adapted by contributions from eight members of the multidisciplinary Leuven University Hospitals Endometriosis Care Program, from 18 international experts and from audience feedback during three international meetings.

MAIN RESULTS AND THE ROLE OF CHANCE

We have developed the DESS to record in detail the surgical procedures for DE, and an international consensus on pre-, intra- and post-operative data that should be recorded in surgical outcome trials on DE.

LIMITATIONS, REASONS FOR CAUTION

The recommendations in this paper represent a consensus among international experts based on a systematic review of the literature. For several items and recommendations, high-quality RCTs were not available. Further research is needed to validate and evaluate the recommendations presented here.

WIDER IMPLICATIONS OF THE FINDINGS

This international expert consensus for standardized reporting of surgical treatment in women with DE, based on a systematic literature review and international consensus, can be used as a guideline to record and report surgical management of patients with DE and as a guideline to design, execute, interpret and compare clinical trials in this patient population.

STUDY FUNDING/COMPETING INTERESTS

None of the authors received funding for the development of this paper. M.A. reports personal fees and non-financial support from Bayer Pharma outside the submitted work; H.T. reports a grant from Pfizer and personal fees for being on the advisory board of Perrigo, Abbvie, Allergan and SPD.

TRIAL REGISTRATION NUMBER

N/A.

Transanal completion proctectomy after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis: a modified single stapled technique

AIM

Minimally invasive surgery has proved its efficacy for the surgical treatment of ulcerative colitis (UC). The recent evolution in single port (SP) surgery together with transanal rectal surgery could further facilitate minimally invasive surgery in UC patients. This technical note describes a technical modification for single stapled anastomoses in patients undergoing transanal completion proctectomy and ileal pouch-anal anastomosis (ta-IPAA) for UC.

METHODS

A step-by-step approach of the ta-IPAA in UC is described, including pictures and a video illustration.

RESULTS

We describe a ta-IPAA with SP laparoscopy at the ileostomy site. All patients underwent a total colectomy with end-ileostomy for therapy refractory UC in a first step. Colectomy was done by multiport laparoscopy in six patients, while the ileostomy site was used as single port access in five patients. In all 11 patients the stoma site was used for SP mobilization of the mesenteric root and fashioning of the J-pouch. Completion proctectomy was done using a transanal approach. A single stapled anastomosis was performed in all patients. An 18 French catheter was used to approximate the pouch to the rectal cuff.

CONCLUSION

A technical modification of the single stapled anastomosis facilitates the formation of the ta-IPAA, further reducing invasiveness in UC patients.

Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown. The aim of this systematic review is to investigate the definitions and incidence of PPOI previously described.

METHOD

MEDLINE, Embase and the Cochrane Database of Systematic Reviews (up to July 2014) were searched. Two authors independently reviewed citations using predefined inclusion and exclusion criteria.

RESULTS

The search strategy yielded 3233 citations; 54 were eligible, comprising 18 983 patients. Twenty-six studies were prospective [17 of these being randomized controlled trials (RCTs)] and 28 were retrospective. Meta-analysis revealed an incidence of PPOI of 10.3% (95% CI 8.4-12.5) and 10.2% (95% CI 5.6-17.8) for non-RCTs and RCTs, respectively. Significant heterogeneity was observed for both non-RCTs and for RCTs. The used definition of PPOI, the type of surgery and access (laparoscopic, open) and the duration of surgery lead to significant variability of reported PPOI incidence between studies. The incidence of PPOI is lower after laparoscopic colonic resection.

CONCLUSION

There is a large variation in the reported incidence of PPOI. A uniform definition of PPOI is needed to allow meaningful inter-study comparisons and to evaluate strategies to prevent PPOI.

Postoperative Inflammatory Response in Crohn's Patients: A Comparative Study

BACKGROUND AND AIMS

Surgery for Crohn's disease [CD] can be complicated by an enhanced inflammatory response. This retrospective study aims to compare the inflammatory response measured by C-reactive protein [CRP] in patients operated for CD with patients undergoing similar surgery for colorectal cancer [CRC].

METHODS

All CD patients undergoing an ileocaecal resection between February 2001 and December 2013 were retrieved from a prospectively maintained database. The same number of patients with a CRC of the ascending colon, undergoing a laparoscopic right hemicolectomy between March 2009 and June 2014, were retrieved from a CRC database. CRP level during the first 7 postoperative days was used as primary outcome.

RESULTS

Totals of 112 consecutive CD patients (male 40.2%; median age: 32.3 yrs; interquartile range [IQR]: 25.2-45.1) and 112 consecutive CRC patients [male 53.6%; median age 71.6 yrs; IQR: 64.7-77.5] were included. Postoperative CRP level in the CD group was on average 27% higher compared with the CRC group [p = 0.02]. The day-specific differences in CRP values were 21% (p = 0.021, 95% confidence interval [CI]: 3% 41%), 41% [p = 0.005, 95% CI: 11%-79%], 49% [p = 0.007, 95% CI: 11%-96%], and 49% [p = 0.006, 95% CI: 12%-100%] higher for CD patients at Days 1, 4, 5, and 6 respectively. The difference in postoperative CRP level was partially due to differences in preoperative CRP level.

CONCLUSION

CD patients develop a higher postoperative CRP level, probably reflecting an enhanced postoperative inflammatory response, which may be triggered by a higher preoperative inflammatory state.

How do patients score cosmesis after laparoscopic natural orifice specimen extraction colectomy?

AIM

Laparoscopic colorectal resection results in improved cosmetic outcome and better presumed body image. Laparoscopic NOSE colectomy omits an incision for specimen extraction and is supposed to further improve postoperative cosmesis. This study aimed to assess the cosmetic benefit.

METHOD

Forty-nine patients who underwent a NOSE colectomy for bowel endometriosis from September 2009 to September 2013 were matched for age, American Society of Anesthesiologists (ASA) grade and body mass index (BMI) with patients who underwent a conventional laparoscopic colectomy for the same indication. Patients were asked to complete a questionnaire consisting of a body scale and a cosmetic scale and the Patient Scar Assessment Questionnaire (PSAQ) including five subscales (appearance, symptoms, scar consciousness, satisfaction with appearance and satisfaction with symptoms).

RESULTS

Patient demographics were similar between both groups. Patients were assessed at a median postoperative follow-up of 41 months in the NOSE colectomy group and 35 months in the conventional resection group. The median body image questionnaire score was 15 for NOSE colectomy and 18 for conventional resection (P = 0.027). The respective median PSAQ scores were 56 and 71 (P = 0.002). There was a good relationship between the PSAQ score and the body image questionnaire (Spearman correlation coefficient 0.82).

CONCLUSION

Depending on the scoring system used, the cosmetic outcome may be better after NOSE colectomy than conventional laparoscopy in patients having surgery for endometriosis. The comprehensive body image questionnaire, being shorter and easier to use, could be a valid tool for assessing cosmesis after NOSE procedures.

COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™)

AIM

Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing(™) in (low) colorectal anastomosis.

METHOD

The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained.

RESULTS

Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses.

CONCLUSION

Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing(™) with conventional stapling is needed.

Laparoscopic NOSE colectomy with a camera sleeve: a technique in evolution

AIM

Although natural orifice specimen extraction (NOSE) reduces abdominal access trauma, specimen retrieval with a bag can be difficult, due to the size of the specimen. This technical note aims to show feasibility of laparoscopic NOSE colectomy with a camera sleeve based on a well-documented video.

METHOD

Over a 9-month period all patients who had laparoscopic NOSE colectomy were included in the study. Camera sleeve extraction was compared with specimen retrieval bag extraction.

RESULTS

Eight patients (6 females, median age 63 years, median BMI 23 kg/m²) underwent NOSE with a camera sleeve versus nine patients with a specimen retrieval bag. Patient characteristics and operative details were similar in both groups. There were no conversions. Median hospital stay was 4 days in both groups.

CONCLUSION

Laparoscopic NOSE colectomy with a camera sleeve is feasible, but it remains to be shown that this technical modification will lead to an increase in indications for left-sided colonic resections.

Randomized clinical trial of laparoscopic colectomy with or without natural-orifice specimen extraction

Background

Although conventional laparoscopic colectomy is a validated technique, laparoscopic natural-orifice specimen extraction (NOSE) colectomy might improve outcome. This randomized clinical trial compared analgesia requirements, postoperative pain, anorectal function, inflammatory response and cosmesis in laparoscopic NOSE colectomy and conventional laparoscopic colectomy.

Methods

Patients were randomly assigned to undergo laparoscopic NOSE colectomy or conventional laparoscopic colectomy for left-sided colonic disease. The primary endpoint was analgesia requirement. Secondary endpoints were operative outcome, inflammatory response, anorectal function and cosmesis.

Results

Forty patients were enrolled in the study, 20 in each group (15 with diverticulitis and 5 with colorectal cancer in each group). A significant difference was observed in morphine analogue requirements (1 of 20 patients in the NOSE group versus 10 of 20 in the conventional group; P = 0·003). Patient-controlled epidural analgesia was lower in the NOSE group (mean 116 ml versus 221 ml in the conventional group; P < 0·001), as was paracetamol use (mean 11·0 versus 17·0 g respectively; P < 0·001). Postoperative pain scores were lower in the NOSE group: mean maximum visual analogue score of 3·5 versus 2·1 (P < 0·001). One week after hospital discharge, pain scores remained higher in the conventional group: 15 of 20 patients in the conventional group reported pain, compared with one of 20 in the NOSE group (P < 0·001). Inflammatory responses were greater in patients undergoing NOSE colectomy: higher peak C-reactive protein and interleukin 6 levels were observed on postoperative day 2 (P < 0·001) and day 1 (P = 0·002) respectively. Postoperative anorectal function, complications and hospital stay were similar in the two groups.

Conclusion

Laparoscopic NOSE colectomy was associated with less pain and lower analgesia requirements than the conventional laparoscopic extraction. Registration number: NCT01033838 (http://www.clinicaltrials.gov).

Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach

AIM

Nerve-sparing surgery during laparoscopic rectal mobilization is still limited by anatomical constraints such as obesity, the narrowness of the male pelvis, an ultra low rectal cancer or all of these. The transanal approach for total mesorectal excision has overcome the shortcomings of limited access to the rectal 'no-man's land' close to the pelvic floor. The aim of this anatomical study was to define a roadmap of anatomical landmarks for the caudal to cephalic approach so as to standardize nerve-sparing rectal mobilization procedures.

METHOD

Macroscopic dissections of the pelvis in a caudal to cephalic direction were performed in eight alcohol-glycerol embalmed cadavers. A roadmap of anatomical landmarks was created at different levels of section to demonstrate the sites of nerve injury.

RESULTS

Extrinsic autonomic nerves to the urogenital organs and the internal sphincter muscle are closely adjacent to the lowest portion of the rectum above the pelvic diaphragm.

CONCLUSION

This anatomical guide for the pelvic surgeon should facilitate a safe and nerve-sparing dissection of the mesorectal plane with a meticulous overview of the lowest autonomic nerve fibres. New anatomical insights by a 'caudal to cephalic' approach to the 'no-man's land' should help overcome anatomical constraints of a narrow, obese and male pelvis during rectal mobilization procedures.

Endoscopic versus radiology-based location of rectal cancer

BACKGROUND

Rigid proctosigmoidoscopy is recommended for measuring the height of rectal neoplasms but appears to be performed in only a minority of patients. Our aim was to compare endoscopic and radiological measurement of rectal tumour location with a focus on differentiation between mid and high rectal cancer.

METHODS

Medical records of 66 rectal cancer patients were reviewed. Tumour location defined at colonoscopy (66 patients), rigid proctosigmoidoscopy (20 patients) and endorectal ultrasound (35 patients) was recorded. Rectilinear and curvilinear methods were used to estimate the distance between the lower tumour level and the anal verge on sagittal CT or MR images (66 patients). Agreement, intra- and inter-observer variation of radiology-based measurements were -assessed using intra-class correlation (ICC) and within-subject coefficient of variation (WSCV).

RESULTS

Tumour location was performed at rigid proctosigmoidoscopy in 30% of patients. Intra- and inter-observer agreement for radiology-based measurements were high. Tumour location using the rectilinear method or proctosigmoidoscopy was similar on average, for a difference of only 0.34 cm (SD 2.0 cm, p = 0.330), although agreement was -moderate (ICC = 0.54, WSCV = 16.7%). Measurements based on colonoscopy and the curvilinear radiological method were -characterized by a systematic overestimation of the location, increasing with tumour height.

CONCLUSIONS

Radiology-based measurement of the lower tumour level is a reproducible alternative for tumour location at rigid or flexible endoscopy. Its validity should be further assessed.

Long-term functional outcome after ileal pouch anal anastomosis in 191 patients with ulcerative colitis

BACKGROUND

A long-lasting good functional outcome of the pelvic pouch and a subsequent satisfying quality of life (QoL) are mandatory. Long-term functional outcome and QoL in a single-center cohort were assessed.

PATIENTS AND METHODS

A questionnaire was sent to all patients with an IPAA for UC, operated between 1990 and 2010 in our department. Pouch function was assessed using the Öresland Score (OS) and the 'Pouch Functional Score' (PFS). QoL was assessed using a Visual Analogue Score (VAS).

RESULTS

250 patients (42% females) with a median age at surgery of 38 years (interquartile range (IQR): 29-48 years) underwent restorative proctocolectomy. Median follow-up was 11 years (IQR: 6-17 years). Response rate was 81% (n=191). Overall pouch function was satisfactory with a median OS of 6/15 (IQR: 4-8) and a median PFS of 6/30 (IQR: 3-11). 24-hour bowel movement is limited to 8 times in 68% of patients (n=129), while 55 patients (29%) had less than 6 bowel movements. 12 patients (6.5%) were regularly incontinent for stools, while 154 patients (82%) reported a good fecal continence. Fecal incontinence during nighttime was more common (n=72, 39%). Pouch function had little impact on social activity (4/10; IQR: 2-6) and on professional activity (3/10; IQR: 1-6). 172 patients (90%) reported to experience an overall better health condition since their operation. The OS and the PFS correlated well (Pearson's correlation coefficient=0.83). Overall pouch function was stable over time.

CONCLUSION

Majority of patients report a good pouch function on the long-term with limited impact on QoL.

The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery : proceedings of a consensus conference

BACKGROUND

It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors.

METHOD

There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction.

RESULT

The oncological rationale for CME and various technical aspects of the surgical management will be explored.

CONCLUSION

The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.