Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Background

Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME.

Methods

Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence.

Results

The implementation cohort of 120 patients had a median follow up of 21·9 months. Short‐term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre).

Conclusion

TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer

Background

Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients.

Methods/Study design

In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients.

Discussion

The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery.

Trial registration

NCT02371304, registration date: February 2015

Evaluation of preoperative geriatric assessment of elderly patients with colorectal carcinoma. A retrospective study

AIMS

Elderly patients with colorectal carcinoma are screened with the Identification of Seniors at Risk (ISAR) questionnaire to identify frail patients. These patients are more at risk for mortality and morbidity and are referred to the geriatric specialist for assessment (Dutch acronym: DOG). The DOG assessment aims to preoperatively optimize the patient in order to improve postoperative outcomes. This study evaluates if the DOG assessment influences postoperative outcome after colorectal surgery.

METHODS

Retrospective cohort and match-control study. Elderly patients who underwent elective resection between 01-01-2008 and 01-08-2013 in the Medical Centre Alkmaar were included. Patients with a positive ISAR score were referred to the geriatric specialists for DOG assessment (DOG patients). DOG assessment encompassed comprehensive geriatric assessment and interventions.

PRIMARY OUTCOMES

Mortality, delirium and length of hospital stay.

SECONDARY OUTCOMES

postoperative complications.

COHORT COMPARISON

Cohort ISAR- (2008-2010, no ISAR questionnaire) is compared with cohort ISAR+ (2011-2013, ISAR questionnaire). Match-control comparison: DOG patients are compared with matched controls from cohort ISAR-.

RESULTS

Compared to their matched controls, DOG patients were older and had a higher prevalence of certain risk factors for postoperative delirium. In both comparisons, no statistical significant differences were found between the groups in mortality and postoperative delirium. Length of stay was significantly shorter in cohort ISAR+.

CONCLUSIONS

While the DOG patients were significantly more at risk for postoperative complications, the DOG patients had comparable postoperative outcomes as their matched controls. We therefore conclude that the DOG assessment has a positive influence on the postoperative outcomes after colorectal surgery.

Body image, cosmesis, quality of life, and functional outcome of hand-assisted laparoscopic versus open restorative proctocolectomy: long-term results of a randomized trial

BACKGROUND

This study aimed to compare quality of life (QOL), functional outcome, body image, and cosmesis after hand-assisted laparoscopic (LRP) versus open restorative proctocolectomy (ORP). The potential long-term advantages of LRP over ORP remain to be determined. The most likely advantage of LRP is the superior cosmetic result. It is, however, unclear whether the size and location of incisions affect body image and QOL.

METHODS

In a previously conducted randomized trial comparing LRP with ORP, 60 patients were prospectively evaluated. The primary end points were body image and cosmesis. The secondary end points were morbidity, QOL, and functional outcome. A body image questionnaire was used to evaluate body image and cosmesis. The Short Form-36 Health Survey and the Gastrointestinal Quality of Life Inventory were used to assess QOL. Body image and QOL also were assessed preoperatively.

RESULTS

A total of 53 patients completed the QOL and functional outcome questionnaires. There were no differences in functional outcome, morbidity, or QOL between LRP and ORP. At a median of 2.7 years after surgery, 46 patients returned the questionnaires regarding body image, cosmesis, and morbidity. The body image and cosmesis scores of female patients were significantly higher in the LRP group than in the ORP group (body image, 17.4 vs 14.9; cosmesis, 19.1 vs 13.0, respectively). The female patients in the ORP group had significantly lower body image scores than the male patients (14.9 vs 18.3).

CONCLUSIONS

This study is the first to show that ORP has a negative impact on body image and cosmesis as compared with LRP. Functional outcome, QOL, and morbidity are similar for the two approaches. The advantages of a long-lasting improved body image and cosmesis for this relatively young patient population may compensate for the longer operating times and higher costs, particularly for women.

Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study

OBJECTIVE

The aim of the study was to evaluate feasibility and safety of restorative proctectomy with ileal pouch anal anastomosis (IPAA) through a Pfannenstiel incision after prior laparoscopic colectomy.

METHODS

Seventeen patients who underwent restorative proctectomy after laparoscopic emergency colectomy for ulcerative colitis (UC) were prospectively evaluated. Results were compared with results of a group of 21 case matched patients that had restorative proctectomy and IPAA via a midline incision in the same period.

RESULTS

Median operation time was longer, although not significantly, in patients who had a restorative proctectomy through a pfannenstiel (186 min) compared to a restorative proctectomy through a midline incision (158 min). Procedure related complications were comparable between the groups, respectively, 1 of 17 patients in the pfannenstiel group and 3 of 21 patients in the median laparotomy group. Median hospital stay in the pfannenstiel group was 10 days and in the midline group 12 days.

CONCLUSIONS

After laparoscopic assisted emergency colectomy for ulcerative colitis, restorative proctectomy is feasible and can be performed safely through a Pfannenstiel incision.

Long-term outcomes and quality of life after laparoscopic adhesiolysis for chronic abdominal pain

STUDY OBJECTIVE

To evaluate clinical outcome in terms of pain and quality of life after laparoscopic adhesiolysis.

DESIGN

Prospective observational study (Canadian Task Force II-3).

SETTING

University-affiliated medical center.

PATIENTS

Twenty-three patients (22 women).

INTERVENTION

Laparoscopic adhesiolysis for chronic abdominal pain.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed by validated McGill score. Patients with an intraindividual decrease in pain score of 5 points or more were considered successes. Quality of life was assessed by the SF-36 and gastrointestinal quality of life index. Patients were evaluated before and at intervals until 2 years after adhesiolysis. The mean pain score before adhesiolysis was 30.5 (range: 17-40). At 2 years of follow-up, 10 (45%) of 22 patients (95% CI 0.244-0.678) were considered successes. They reported significant improvement in quality of life on scales physical, role physical, and social function, and fewer gastrointestinal symptoms. Twelve women (55%) had a complete relapse, and most were not motivated to visit the pain clinic after 6 months.

CONCLUSION

Laparoscopic adhesiolysis for chronic abdominal pain was successful in only 45% of patients.

Interleukin-6, C-reactive protein, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells in patients after laparoscopic vs. conventional bowel resection: a randomized study

PURPOSE

The aim of the study was to investigate the effect of surgical trauma in terms of approach (laparoscopic vs. conventional surgery) and extent of bowel resection (ileocolic resection vs. colectomy) on interleukin-6 level, C-reactive protein level, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells. Second, the length of the incision was correlated with the inflammatory response.

METHODS

Thirty-four patients were analyzed as part of a randomized trial comparing laparoscopically assisted vs. open bowel resection for Crohn's disease, ulcerative colitis, and familial adenomatous polyposis. C-reactive protein levels and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells were measured preoperatively and one day after surgery. Interleukin-6 was measured preoperatively and on Days 1 and 7 postoperatively.

RESULTS

Four of the 34 patients were excluded because of blood transfusion after surgery. One day postoperatively, the interleukin-6 level peaked significantly within the laparoscopic and conventional group. There was no significant difference between the conventional and laparoscopic groups at Day 1 postoperatively. At Day 7 postoperatively, interleukin-6 levels were similar in both groups and returned to baseline levels. There was a higher C-reactive protein level in the conventional group one day after surgery than in the laparoscopic group, although the difference was not significant. Preoperative and postoperative human leukocyte antigen-DR expression on monocytes and postoperative percentage of lymphocytes expressing human leukocyte antigen-DR did not differ between the conventional and laparoscopic groups. No differences in immune response with respect to the measured parameters were noticed in patients with a large or small bowel resection segment or in patients with a small (</=8 cm) or large (>8 cm) incision.

CONCLUSIONS

These data suggest that surgical trauma did not significantly affect the immune status of patients with respect to the measured parameters in terms of either the approach or the extent of bowel resection.

Laparoscopic surgery for inflammatory bowel disease: current concepts

BACKGROUND

The aim of a laparoscopic approach is reduced pain scores, early mobilization, virtual absence of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital and return to normal activity and improved cosmetics. Potential advantages are fewer complications due to adhesion formation, viz. small-bowel obstruction, infertility and chronic abdominal pain-advantages that are of particular importance to patients with inflammatory bowel disease (IBD) since they are young and in the middle of building up their socio-economic life. This review highlights the current status of laparoscopic surgery for patients with IBD.

METHODS

Virtually all abdominal procedures carried out in patients with IBD can be done laparoscopically, and vary from stoma formation to restorative proctocolectomy.

RESULTS

Conversion rates and operating times depend on the surgical expertise and patient-related factors, viz. prior laparotomy, the presence of intestinal fistula or inflammatory masses. Morbidity rates are similar to those of open surgery provided that the procedures are done by expert laparoscopic surgeons. The observed earlier recovery contributed to laparoscopic surgery has not been proved in well-conducted trials; however, an advantage can be expected. A very obvious feature of laparoscopic surgery is the improved cosmetics, which might turn out to be the most important advantage of the laparoscopic approach in this relatively young patient group.

CONCLUSION

The laparoscopic approach can be considered the procedure of first choice in patients with IBD provided the surgery is done by expert laparoscopists ensuring low conversion rates, acceptable operating times and low morbidity.

Randomized study of the effectiveness of closing laparoscopic trocar wounds with octylcyanoacrylate, adhesive papertape or poliglecaprone

BACKGROUND

Several methods for skin closure are used, i.e. sutures, adhesive papertape and tissue adhesives. Little is known about the efficacy of these techniques in laparoscopic surgery. This study was performed to analyse the efficacy of octylcyanoacrylate, a new tissue adhesive, adhesive papertape and poliglecaprone for wound closure in laparoscopy.

METHODS

From May 2000 to September 2001, 140 patients were included in a prospective randomized trial. Wounds were closed with octylcyanoacrylate (n = 48), adhesive papertape (n = 42) or poliglecaprone (n = 50). Closing time, wound infection, cosmetic results and costs were evaluated. A time-motion analysis was also performed.

RESULTS

The patients in the three groups were well matched for age, gender and body mass index. Closing times per wound were 26, 33 and 65 s respectively for adhesive papertape, octylcyanoacrylate and poliglecaprone (P < 0.001). Cosmetic results, as scored by the patients, were no different. The number of actions required to close each wound was 5.7, 8.3 and 21.0 for octylcyanoacrylate, adhesive papertape (P = 0.05 versus octylcyanoacrylate) and poliglecaprone (P < 0.01 versus octylcyanoacrylate and adhesive papertape) respectively. Octylcyanoacrylate was significantly more expensive than poliglecaprone and adhesive papertape.

CONCLUSION

Closure with adhesive papertape was the fastest method. The smallest number of actions required to close a wound was with octylcyanoacrylate. Adhesive papertape was the most cost-effective.

Efficiency of manual versus robotical (Zeus) assisted laparoscopic surgery in the performance of standardized tasks

BACKGROUND

The objective of this study was to compare the efficiency of manual and robotically assisted laparoscopic surgery.

METHODS

To evaluate the surgical efficiency in a set of basic endoscopic movements, 20 medical students without any surgical experience were selected to perform at random a set of laparoscopic tasks either manually or robotic assisted (Zeus). This task consisted of dropping beads into receptacles, running a 25-cm rope, capping a hypodermic needle, suturing, and performing a laparoscopic cholecystectomy on a cadaver liver of a pig. A quantitative time-action analysis was performed to evaluate the efficacy and skill performance in terms of time and the number of actions.

RESULTS

The dropping beads exercise and the laparoscopic cholecystectomy required more time when performed with robotic assistance, as compared with manual performance (respectively, median, 78.5 s; range, 63 - 122 s vs median, 144.5 s; range, 100 - 169 s; p <0.01 and median, 34.0 min; range 11-44 min vs median, 46.5 s; range, 21 - 79 min; p = 0.05). A tendency toward fewer total actions in all the robotically assisted exercises was observed. However, significance was shown only in the rope-passing task (median, 71; range, 59 - 87 vs median, 62; range, 57-80; p = 0.05). Grasping the beads, the rope, and either the needle or the cap were tasks that required fewer actions to complete when performed with robotically assistance (respectively, median, 11; range, 10 - 14 vs median, 12.5; range, 11 - 15; p <0.01; median, 56; range, 55 - 60 vs median, 60.5 min; range, 55 - 65; p = 0.03, and median, 6; range, 4 - 21 vs median, 10.5; range, 6 - 38; p = 0.02). As compared with the robotically assisted rope-passing exercise, more failures were made in the manually performed procedure (p = 0.03), mainly caused by unintentional dropping of the rope (p = 0.02).

CONCLUSIONS

Robotically assisted laparoscopic surgery by participants without any surgical experience might require more time, but actions can be performed equally or more precisely as compared with manual laparoscopic surgery.

Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study

PURPOSE

The aim of this study was to assess the functional outcome and the quality of life of laparoscopic-assisted ileal pouch-anal anastomosis compared with conventional ileal pouch-anal anastomosis. Further, body image and cosmesis were evaluated in both groups.

METHODS

Sixteen patients who underwent a laparoscopic-assisted ileal pouch-anal anastomosis between March 1996 and September 1999 were matched with 19 patients who had a conventional ileal pouch-anal anastomosis. Patients were matched for the time period after surgery, distribution of familial adenomatous polyposis/ulcerative colitis, and one/two-stage procedure. Thirty-two patients agreed to fill out a set of questionnaires that assessed functional outcome, quality of life, body image, and cosmesis. Quality of life was measured with the Short Form 36 Health Survey questionnaire and the Gastrointestinal Quality of Life Index. The Body Image Questionnaire was used to measure patients' perceptions of and satisfaction with their own body and their attitude toward their bodily appearance (body image) and the degree of satisfaction of patients with respect to the physical appearance of the scar (cosmesis).

RESULTS

Patients in the conventional group were older than patients in the laparoscopic-assisted group (mean 39.2 +/- 8.4 vs. 30.6 +/- 7.1 years; P < 0.01). No differences were found in functional outcome and quality of life. Satisfaction with the cosmetic result of the scar was significantly higher in the laparoscopic-assisted group compared with the conventional group. Body image score was higher in the laparoscopic-assisted group when compared with the conventional group, although not significant.

CONCLUSIONS

The functional outcome and quality of life of laparoscopic-assisted ileal pouch-anal anastomosis is not different from conventional ileal pouch-anal anastomosis. In the long-term, better cosmesis is the most important advantage after laparoscopic surgery.

Efficacy of establishment of pneumoperitoneum with the Veress needle, Hasson trocar, and modified blunt trocar (TrocDoc): a randomized study

PURPOSE

To compare three techniques of establishment of pneumoperitoneum for efficacy: the Veress needle/first trocar, the Hasson trocar, and a newly developed modified blunt trocar, the TrocDoc.

PATIENTS AND METHODS

Between June and December 1999, 62 patients eligible for laparoscopic surgery were randomized. The effectiveness of installation of the pneumoperitoneum using the three techniques was assessed by time-motion analysis. Primary efficacy measures were total time and number of actions required to establish the pneumoperitoneum. Secondary efficacy measures were procedure-related complications, wound complications, and occurrence of CO2 leakage.

RESULTS

Two patients were withdrawn from inclusion. The three groups were comparable for age and body mass index. Total time was shortest using the TrocDoc rather than the Veress needle/first trocar and the Hasson trocar (respectively, 138 +/- 58 v 237 +/- 56 v 350 +/- 103 seconds), and the number of actions was lowest for the Veress needle/first trocar combination: 22 +/- 7 v 32 +/- 12 (TrocDoc) v 53 +/- 17 (Hasson). There was no morbidity related to the installation of pneumoperitoneum nor trocar wound complications. Gas leakage occurred in five of the Hasson introductions.

CONCLUSIONS

Establishment of the pneumoperitoneum is more efficient using the TrocDoc compared with the Veress needle/first trocar and the Hasson trocar. The TrocDoc might replace the two alternatives because of its efficacy and open method of introduction.

Laparoscopic-assisted vs open colectomy for severe acute colitis in patients with inflammatory bowel disease (IBD): a retrospective study in 42 patients

BACKGROUND

Inflammatory bowel disease (IBD) can be complicated by severe acute colitis. Emergency colectomy is mandatory if patients do not respond to intensive medical therapy. A minimally invasive approach such as laparoscopic-assisted colectomy might be beneficial in these patients. Therefore, we set out to assess the feasibility and the safety of emergency laparoscopic-assisted colectomy in IBD patients with severe acute colitis.

METHODS

A total of 42 consecutive patients underwent an emergency colectomy with end-ileostomy. Ten patients had laparoscopic-assisted colectomy, and 32 had open colectomy. Pre- and perioperative parameters, morbidity, and mortality were analyzed.

RESULTS

The two groups were comparable for patient characteristics. There were no conversions in the laparoscopic group. The operation time was longer in the laparoscopic group than in the open group (271 vs 150 min; p < 0.001), but the hospital stay was shorter (14.6 vs 18.0 days; p = 0.05). Complications were similar for the two groups.

CONCLUSION

Laparoscopic-assisted colectomy in IBD patients with severe acute colitis is feasible and as safe as open colectomy.

Laparoscopic-assisted vs. open ileocolic resection for Crohn's disease. A comparative study

BACKGROUND

The objective of this study was to compare laparoscopic-assisted ileocolic resection for Crohn's disease of the distal ileum with open surgery in two consecutive groups of patients.

METHODS

From 1995 until 1998, 48 patients underwent open ileocolic resection at the Academic Medical Center (AMC) in Amsterdam, while 30 patients had laparoscopic-assisted ileocolic resection at the Leiden University Medical Center (LUMC). Patient characteristics, perioperative course, and recovery were compared. Differences between the groups were tested using Student's t-test for independent groups and chi-square tests when appropriate.

RESULTS

The open and the laparoscopic patient groups were comparable for age, gender, body mass index (BMI), prior abdominal surgery, and length of resected bowel. The conversion rate was 6.6%. Laparoscopic operating times (138+/-SD 36 min) were significantly longer than those observed in the open group (104+/-SD 34 min). Discharge was significantly earlier in the laparoscopic group than the open group (5.7 vs 10.2 postoperative days, p<0.007). Postoperative morbidity did not differ significantly between the patients treated traditionally (14.6%) and laparoscopically (10%).

CONCLUSION

Compared to open surgery, laparoscopic ileocolic resection for Crohn's disease is associated with similar morbidity rates, a shorter hospital stay, and improved cosmetic results, justifying the laparoscopic approach as the procedure of choice.

Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn's disease

BACKGROUND

The objectives of this study were to evaluate body image, cosmetic results, and quality of life in patients with Crohn's disease of the terminal ileum who had either laparoscopic-assisted or open ileocolic resection, and to determine how patients experienced the pre- and postoperative periods after both procedures.

METHODS

Thirty-four patients participated: 11 patients after open resection (OR), 11 patients after laparoscopic-assisted resection (LR), and 12 patients without resection (WR). Retrospectively, the patients filled out several questionnaires pertaining to body image, hospital experiences, and quality of life. One-way analysis of variance, Student's t-tests, and Pearson's correlation were used for statistical analysis.

RESULTS

The cosmetic score was significantly higher in the LR than in the OR group (p < 0.01). Body image correlated strongly with cosmesis and with quality of life. The hospital experiences of the laparoscopic and open groups were similar.

CONCLUSIONS

Laparoscopic surgery was associated with better cosmesis than open surgery. Patients do not experience laparoscopic surgery any differently from open surgery.