The Extraperitoneal Approach to Left-Sided Colorectal Rectal Resections: EXPERTS Procedure

BACKGROUND

Current transperitoneal approaches to colorectal resections can be technically challenging, especially in obese patients. The head-down position can lead to rare but serious complications, e.g. compartment syndrome and brachial plexus injuries.

OBJECTIVE

The aim of this study was to assess the safety and feasibility of a novel extraperitoneal approach in patients requiring anterior resection.

METHODS

The extraperitoneal left-sided approach was performed in the supine position. A 5 cm LIF incision was created into which a Gelpoint port was inserted. The full video of the procedure is embedded in the QR code below. The procedure was performed by three surgeons with experience in minimally invasive surgery. Patients requiring left colonic resections were prospectively selected over a 2-year period.

RESULTS

Forty-one patients were prospectively assessed between March 2020 and April 2022; 26 were males, with a median age of 67 (55-88) years. The average body mass index (BMI) was 30 (22-40). 38/41 cases were cancers and three were diverticular diseases; 31 cases had anterior resection and 11 had sigmoid colectomies. Peak airway pressures were significantly less (10 cmH20) in the supine position compared with the head-down position (p < 0.0001). Median time to identify the ureter and gonadal vessels was 23 (3-55) min, and median time to return of bowel function and length of stay was 2 (0-13) and 5 (IQR 3-7) days, respectively. No intraoperative complications or postoperative mortality occurred within 90 days of discharge. Three patients had anastomotic complications, and an R0 resection was achieved in all 38 cancer patients. The median lymph node count was 16.

CONCLUSION

Extraperitoneal surgery for left colonic resections is safe and clinically feasible, and allows for early identification of important retroperitoneal structures.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

INTRODUCTION

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position.

METHODS

The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure.

RESULTS

Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures.

CONCLUSIONS

This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Resource implications of running a sacral neuromodulation service: a 10-year experience

AIM

In this study we reviewed our 10-year experience of the medium- to long-term success of sacral nerve stimulation (SNS) for faecal incontinence, with particular reference to the resource implications of running such a service.

METHOD

All patients treated with permanent SNS implants for faecal incontinence from 2001 to 2012 were identified from a prospective database. The patients underwent follow up at 3 and 6 months, with annual review thereafter. They were divided into four groups: group 1, patients optimized after two reviews; group 2, patients optimized after further review; group 3, patients who failed to reach a satisfactory state; and group 4, patients who had a good initial result with subsequent failure.

RESULTS

Eighty-five patients underwent permanent SNS with a median follow up of 24 (range: 3-108) months. Group 1 included 30 (35%) patients; group 2 included 27 (32%) patients [median of two (range: 2-6) additional visits]; group 3 included 18 (21%) patients [median of six (range: 3-10) additional visits]; and group 4 included 10 (12%) patients [median interval to failure was 54 (range: 24-84) months]. Twenty-seven per cent of our patients had an unsatisfactory outcome and the cost of follow up for these patients was £36,854 (48.7% of the total follow-up costs).

CONCLUSION

The study highlights the significant resource implications of running an SNS service with a large proportion of patients requiring prolonged review, with more than one-quarter having an unsatisfactory outcome at a substantial cost.

Does sacral nerve stimulation improve global pelvic function in women?

AIM

Many women undergoing sacral neuromodulation for faecal incontinence have coexisting pelvic floor dysfunction. We used a global pelvic-floor assessment questionnaire to evaluate the effect of sacral neuromodulation on non-bowel related symptomatology.

METHOD

The electronic Personnel Assessment Questionnaire - Pelvic Floor (ePAQ-PF) is a validated Web-based electronic pelvic floor questionnaire. Women with faecal incontinence underwent assessment using the ePAQ. Pre- and poststimulator data were analysed over a 4.5-year period.

RESULTS

Forty-three women (mean age 56.5 years; median follow up 6.8 months) were included. All (100%) had urinary symptoms, 81.4% had vaginal symptoms and 85.7% described some sexual dysfunction. There was a significant improvement in faecal incontinence and in bowel-related quality of life (P < 0.005) as well as in irritable bowel syndrome (IBS)-related symptoms (P < 0.01) and in bowel-related sexual heath (P < 0.01). Symptoms of vaginal prolapse significantly improved (P = 0.05). There was also improvement in symptoms of overactive bladder (P = 0.005) and in urinary-related quality of life (P < 0.05). A global health improvement was reported in 58.1%, mainly in bowel evacuation (P < 0.01) and in vaginal pain and sensation (P < 0.05). In sexually active female patients, significant improvements in vaginal and bowel-related sexual health were seen (P < 0.005). Improvement in general sex life following stimulation was reported in 53.3%.

CONCLUSION

A Web-based electronic pelvic-floor assessment questionnaire has demonstrated global improvement in pelvic floor function in bowel, urinary, vaginal and sexual dimensions in women following sacral neuromodulation for faecal incontinence.

The association between prucalopride efficacy and constipation type

BACKGROUND

Prucalopride is a selective serotonin receptor agonist with prokinetic activity, indicated for women with chronic constipation in whom laxatives have failed to provide adequate relief. Data suggests an improvement in about 50 % of such patients but whether the therapeutic effect is on patients with slow transit constipation (STC) and/or obstructed defaecation syndrome (ODS), or even those with constipation-predominant irritable bowel syndrome (IBS-C) is unknown. We therefore assessed whether there is any association between prucalopride efficacy and constipation type.

METHODS

All patients receiving prucalopride between June 2010 and April 2012 at our institution were identified, and data analysed following a 4-week "test" period. Patients were sub-grouped as those suffering with ODS, STC, mixed (ODS and STC) or IBS-C based on symptomatology and investigations. Subjective assessment of patient satisfaction and continuation of medication were taken as positive outcomes and analysed for each sub-type along with any side effects.

RESULTS

Sixty-nine patients met our criteria. Data were available for 59 women (median age 46 years, range 17-79 years). Sixty-five per cent of prescriptions came from colorectal surgeons. Overall, 25 out of 59 (42 %) patients improved, according to our criteria, after the 4-week trial period. Seventeen patients (29 %) had ODS, 26 (44 %) had STC, 7 (12 %) had mixed symptoms and 9 (15 %) had IBS-C. At 4 weeks, 10 out of 17 patients (59 %) with ODS had improved compared with 4 out of 9 patients (44 %) with IBS-C, 3 out of 7 patients (43 %) with mixed symptoms and 8 out of 26 (31 %) patients with STC. The underlying disorder did not predict whether or not a patient responded to the 4-week trial period (p = 0.32). Nine patients (15 %) experienced side effects that precluded further use.

CONCLUSIONS

Patients with all categories of constipation may respond to prucalopride. A trial regime may be indicated regardless of the aetiology of the constipation.

Metachronous bilateral adrenal metastases following curative treatment for colorectal carcinoma

A delayed, metachronous presentation of bilateral adrenal metastases following colorectal cancer has never previously been reported. We describe the case of a 68-year-old man who underwent curative surgery and adjuvant chemotherapy for a locally invasive sigmoid adenocarcinoma, only to be diagnosed with metachronous bilateral adrenal metastasis necessitating further resection and chemotherapy. We discuss the literature surrounding this pathology and highlight the importance of continual, vigilant radiological surveillance of the adrenal glands after curative treatment of colorectal carcinoma with or without subsequent adrenal metastasis.

Solitary colonic metastasis from renal cell carcinoma presenting as a surgical emergency nine years post-nephrectomy

Late colonic metastasis following curative surgery for renal cell carcinoma has rarely been described. We present the first reported case of solitary colonic renal cell carcinoma metastasis presenting as an intra-abdominal bleed, nine years post-nephrectomy.