Colorectal Surgeons Research Articles

Impact of Surgeon Specialization on Outcomes in Emergency Colorectal Surgery: A Systematic Review and Meta-Analysis.

Colorectal emergencies represent a large proportion of acute general surgical workload and carry significant mortality. Identify the influence of surgeon specialization on mortality and other outcomes in emergency colorectal surgery. Systematic searches of Ovid MEDLINE, Ovid EMBASE, and Cochrane electronic databases were performed for studies published from 1 January 1990 to 27 August 2023. Studies were included investigating outcomes in emergency colorectal surgery for adults, comparing colorectal against non-colorectal surgeon specialization. Exclusion criteria were: (1) publications studying primarily pediatric populations; (2) studies incorporating patients who had undergone surgery prior to 1990; (3) studies only published in abstract form or non-English language. Primary outcomes were 30-day mortality and in-hospital mortality. Secondary outcomes were rates of anastomotic leak, reintervention, primary anastomosis, and laparoscopic approach. Of 7676 studies identified, 155 were selected for full-text review and 21 studies were included for quantitative analysis. Eleven studies showed improved 30-day (OR 0.64, 95% CI 0.60-0.68, p < 0.0001) and in hospital mortality (OR 0.66, 95% CI 0.49-0.89, p = 0.007) with colorectal specialization. There was a significantly higher rate of primary anastomosis (OR 2.95, 95% CI 2.02-4.31, p < 0.0001) and use of laparoscopic surgery (OR 2.38, 95% CI 1.42-4.00, p = 0.001) amongst specialized colorectal surgeons. Specialization was also associated with a significant reduction in any stoma formation (OR 0.52, 95% CI 0.28-0.98, p = 0.04). No significant difference was observed for anastomotic leak (OR 0.70, 95% CI 0.45-1.07, p = 0.10) or reintervention rates (OR 0.78, 95% CI 0.55-1.10, p = 0.16). Heterogeneity exists within the included patient populations and definitions of colorectal specialization observed in different countries. Emergency colorectal surgery undertaken by specialized colorectal surgeons is associated with significantly improved post-operative mortality, lower rates of stoma formation and increased rates of primary anastomosis and minimally invasive surgery. CRD42022300541.

A study of intersphincteric resection rate following robotic-assisted total mesorectal excision versus laparoscopic-assisted total mesorectal excision for patients with middle and low rectal cancer: study protocol for a multicenter randomized clinical trial

IntroductionRobotic-assisted complete mesorectal excision (RATME) is increasingly being used by colorectal surgeons. Most surgeons consider RATME a safe method, and believe it can facilitate total mesorectal excision (TME) in rectal cancer, and may potentially have advantages over intersphincteric resection (ISR) and anus preservation. Therefore, this trial was designed to investigate whether RATME has technical advantages and can increase the ISR rate compared with laparoscopic-assisted TME (LATME) in patients with middle and low rectal cancer.Methods and analysisThis is a multicenter, superiority, randomized controlled trial designed to compare RATME and LATME in middle and low rectal cancer. The primary endpoint is the ISR rate. The secondary endpoints are coloanal anastomosis (CAA) rate, conversion to open surgery, conversion to transanal TME (TaTME), abdominoperineal resection (APR) rate, postoperative morbidity and mortality within 30 days, pathological outcomes, long-term survival outcomes, functional outcomes, and quality of life. In addition, certain measurements will be conducted to ensure quality and safety, including centralized photography review and semiannual assessment.DiscussionThis trial will clarify if RATME improves ISR and promotes anus preservation in patients with mid- and low-rectal cancer. Furthermore, this trial will provide evidence on the optimal treatment strategies for RATME and LATME in patients with mid- and low-rectal cancer regarding improved operational safety.Trial registrationClinicalTrials.gov NCT06105203. Registered on October 27, 2023.

SURGICAL TREATMENT OF RECTAL CANCER WITH PRESERVATION OF THE LEFT COLIC ARTERY AND ICG NAVIGATION

Goal. To analyze the peculiarities of surgical diagnosis of lymphogenic metastasis in patients with colorectal cancer. Generalization of data from Ukrainian and foreign literature, results of randomized studies and meta-analyses. The study is based on the results of observation of 88 patients with colorectal cancer (CRC) of the prospective study group. To analyze the features of surgical diagnostics of lymphogenic metastasis in patients with colorectal cancer. Materials and methods. The results of surgical treatment of 88 patients with rectal cancer were analyzed and systematized. These patients underwent examination and treatment in 2023-2024 at the "Prykarpattian Clinical Oncology Center of the Ivano-Frankivsk Regional Council." The study included patients with stage II-III colorectal cancer (T2-3N0-2M0) without complicated courses. All patients received treatment based on NCCN recommendations. Surgical treatment was performed in standard volume with the removal of all regional lymph node groups and preservation of the left colic artery using real-time lymph node mapping with indocyanine green. All patients were divided into two study groups: Group I included 45 patients who underwent anterior or low anterior resection of the rectum with preservation of the left colic artery. This group was subdivided into two subgroups: Ia – 13 patients who underwent intraoperative indocyanine green injection for real-time lymph node visualization. Ib – 32 patients who did not receive this drug but underwent the same volume of surgery. Group II consisted of 43 patients who underwent anterior or low anterior resection of the rectum with high ligation of the inferior mesenteric artery. This group served as the control group. Results. The main mechanisms of lymphogenic metastasis in colorectal cancer patients in Ivano-Frankivsk were characterized. Literature data on the features of surgical diagnostics of colorectal cancer metastasis were summarized. A review of literature shows the social significance of these studies, as this pathology often leads to patient disability, requiring surgical interventions and further palliative treatment due to the widespread metastasis associated with this disease. The priority task for researchers remains the search for the most effective treatment methods for this pathology, based on randomized studies of colorectal cancer treatment and international protocols. According to the literature, surgical treatment of colorectal cancer remains insufficiently effective at the current stage of oncology. Modern methods offer low 5-year survival rates, emphasizing the need to study factors for individualized treatment. The overall 5-year survival rate for colorectal cancer patients from 2018-2022 was (45.8±2.3)%. The effectiveness of using real-time ICG navigation for lymph node mapping and preservation of the left colic artery in stage II-III (T2-4N1-2M0) rectal cancer patients has been proven. This technique allows for optimal lymphadenectomy, reducing the frequency of surgical complications by 14.7% (p&lt;0.05). Conclusion. Ensuring radical resection of rectal cancer while maximizing blood supply preservation to the anastomosis is the main goal of colorectal surgeons. Over the past two decades, surgical techniques have significantly improved due to advancements in surgical equipment. It is anticipated that surgical technologies will further evolve towards enhancement and individualization in the future. Our procedure serves as an example of modern and personalized rectal cancer surgery.

The impact of standardized robotics course training during colorectal surgery fellowship on post-training practice: a survey of graduates

The Association of Program Directors for Colon and Rectal Surgery (APDCRS) has sponsored a standardized robotics course for colorectal and minimally invasive surgery fellows since 2011. The study objective was to assess the impact of the APDCRS-sponsored course on surgical approaches adopted by young colorectal surgeons before, during, and after fellowship. An internet-based survey was administered to 2014–2022 ACGME-accredited colorectal surgery program graduates. Study variables were summarized using frequencies and proportions. Survey response rate was 43.2%. Laparoscopic and robotic volumes were consistently higher than open and hand-assist laparoscopic volumes over the study period. About 70.0% of fellows performed ≥ 20 laparoscopic cases before 2017, and over 80% had experience with ≥ 20 laparoscopic cases during/after 2017. An increasing trend of performing ≥ 20 robotic colorectal cases during fellowship was observed (before 2017: 75.0%, 2018–2019: 76.9%, and 2021–2022: 84.8%). Multivariate logistic regression analysis showed that higher robotic volume (≥ 25 colorectal cases) during general surgery residency increased odds of performing ≥ 50 robotic cases during fellowship (OR: 4.38, 95% CI 0.88, 26.1). Higher robotic volumes during fellowship correlated with higher robotic volumes in the first year of post-fellowship practice. 88.6% of respondents agree (21.0%) or strongly agree (67.6%) that the APDCRS robotics training course met expectations, and 83.8% agree or strongly agree that the course prepared them for post-graduate robotics practice. The APDCRS-sponsored robotics training course met expectations and prepared colorectal surgery fellows for adopting the robotic approach after graduation, with the majority of respondents reporting that they utilize robotics in their post-graduation colorectal practice.

Getting a colonoscopy at The Valley Hospital.

71 Background: Colorectal cancer (CRC) is the 3rd most common cancer in the U.S., yet it is preventable with evidence-based strategies such as early screening. The Valley Hospital (TVH) located in Bergen County NJ, is recognized for its high insured payer mix and median household income. According to the 2016 TVH Community Health Needs Assessment, only 71.4% of patients in TVH service area have had a CRC screening. The American Cancer Society National Colorectal Cancer Roundtable (NCCRT) campaigned to reach CRC screening rates of 80% and higher in communities across the nation. The Fast Track Screening Colonoscopy Program (FTSCP) at TVH was created to streamline the process of obtaining a screening colonoscopy and reach the NCCRT’s goal. Through the FTSCP, patients can omit the initial consultation with a gastroenterologist or colorectal surgeon. Patients are instead screened via a telephone call by a Physician Assistant (PA) or Advanced Practice Nurse (APN). The FTSCP is cost effective for patients as it potentially eliminates the initial consultation copayment and/or coinsurance. Methods: The purpose of the FTSCP is to achieve the NCCRT’s 80% goal of CRC screenings in TVH service area. An interdisciplinary team of gastroenterologists, colorectal surgeons, oncologists, anesthesiologists, and administration collaborated to create the FTSCP. A screening questionnaire was developed using the Lincoln Hospital in NYC’s existing criteria for patients who are eligible for a direct endoscopy referral. The questionnaire criteria ensures patients are safe to eliminate the initial consultation. A PA or APN determines the patients’ eligibility for the FTSCP over a screening telephone call. To qualify, patients cannot have significant medical comorbidities or exhibit signs or symptoms of CRC. If deemed eligible, the PA or APN sends a bowel preparation prescription to the patient’s pharmacy, reviews the instructions with them, and meets with them on the day of the procedure at TVH to perform a pre-procedural physical exam. To promote awareness and education of the FTSCP, multiple ongoing outreach events are held in the community. Patients also learn about the FTSCP through primary and specialty care referrals. Results: Since the inception of FTSCP in 2018, over 1300 patients have been screened for CRC. Additionally, adenocarcinomas, carcinoid tumors and tubular adenomas with high grade dysplasia have been detected. 394 tubular adenomas (30%) were identified and removed. In 2018, 59 patients were screened. The number of patients increased by 500% to 296 in 2023. The 2022 TVH Community Health Needs Assessment showed an increase to 79.6% of patients in TVH service area who have undergone CRC screening. Conclusions: The FTSCP at TVH is maximizing patient’s access to the prevention and timely screening for CRC. Additionally, TVH’s relocation from Ridgewood, NJ to Paramus, NJ offers further opportunities to educate a new community on CRC prevention.

FP7.13 - Is There A Difference In Anastomotic Leak Rates Requiring Re-Operation Following Emergency Right Hemicolectomy Between Colorectal And Non-Colorectal Surgeons?

Abstract Aim Right sided colonic cancers can often obstruct and present as an emergency. The decision to perform an anastomosis following the right hemicolectomy resection is often multifactorial. This study explores whether there are differences in leak rates between colorectal and non-colorectal surgeons in the context of emergency right hemicolectomy operations performed for malignancy. Methods A retrospective study was conducted at a 3-site Trust in South-East England between 2017 and 2022. Theatre and Infoflex Cancer records were used to obtain patients who had undergone an open right hemicolectomy for malignancy and their operating surgeon. Discharge summaries and clinic letters were then used to ascertain return to theatre for an anastomotic leak. Results There were 281 patients who had undergone an emergency right hemicolectomy in this time interval. There was a 152:129 female:male ratio. 17 out of 37 patients had an anastomosis undertaken by an Upper Gastrointestinal Surgeon. 2 out of the 17 (12%) had an anastomotic leak. 129 out of 244 had an anastomosis undertaken by a Colorectal Surgeon. 17 of the 129 (13%) had an anastomotic leak. There was no significant difference between the leak rates between colorectal and non-colorectal surgeons (p=0.888). Conclusion The study shows that there is no statistical difference in right hemicolectomy anastomotic leak rates between colorectal and non-colorectal surgeons in the emergency setting.

FP3.15 - Are non-colorectal surgeons more likely to make a stoma in an emergency right hemicolectomy for cancer?

Abstract Introduction Right sided colonic cancers can often cause bowel obstruction and present as an emergency. The decision to perform an anastomois following a right hemicolectomy resection is frequently multifactorial. There is controversy as to whether colorectal cancers should be operated on by non-colorectal surgeons in the emergency setting. This study explores whether there are differences in stoma formation rates between colorectal and non-colorectal surgeons in the context of emergency right hemicolectomy operations performed for malignancy. Methods A retrospective study was conducted at a 3 site Trust in South East England between 2017 and 2022. Theatre and Infoflex Cancer records were used to obtain patients who had undergone an open right hemicolectomy for malignancy and their operating surgeon. Results There were 281 patients included in the study, in a 152:129 female:male ratio. The mean age was 68 (34-86 IQR). 13% (37/281) of operations were conducted by Upper Gastro-intestinal Surgeons. 54% (20/37) of these patients had stoma formation as part of their operation. 47% (115/244) of operations undertaken by colorectal surgeons also had stoma formation. There was no significant difference between the stoma formation between colorectal and non-colorectal surgeons (p=0.108) Conclusion The study shows that although the decision to form a stoma following a right hemicolectomy multifactorial and is dependent on a wealth of patient and operative factors, there is no statistical difference between colorectal and non-colorectal surgeons in the emergency setting.

SP3.6 - Do non-colorectal surgeons produce an inferior lymph node yield in emergency colorectal cancer resections?

Abstract Introduction Lymph node yield is a surrogate indicator of adequate resection and yields of 20 or more have been shown to be associated with better survival outcomes. There is controversy as to whether colorectal cancers should be operated on by non-colorectal surgeons in the emergency setting. This study explores whether there are differences in lymph node yield between colorectal and non-colorectal surgeons in the context of emergency Hartmann's procedures performed for malignancy. Methods A retrospective study was conducted at a 3-site Trust in South East England between 2012 and 2022. Theatre and Info flex Cancer records were used to obtain patients who had undergone a Hartmann's procedure for malignancy and their operating surgeon. The histology reports were then reviewed and statistical analysis was undertaken. Results 346 patients were included in the study, in a 197:149 male-to-female ratio. The mean age was 73 (28-92 IQR). Histology confirmed malignancy in all the study participants. 11% (38/346) of the operations were conducted by non-colorectal surgeons (UGI, Breast, and Endocrine). The mean lymph node yield for the non-colorectal surgeons was 28 (24-33 IQR). The mean lymph node yield for colorectal surgeons was 29 (26-34 IQR). There was no statistical difference between the lymph node yield between colorectal and non-colorectal surgeons (p=0.671) Conclusion The study concluded that adequate oncological colonic resections could be conducted safely by non-colorectal surgeons in emergency settings.

FP1.3 - SPEC MDT in Aneurin Bevan University Health Board

Abstract Aims The SPEC (significant polyp and early cancer) multi-disciplinary team (MDT) meeting was started in ABUHB in 2022 to discuss complex colonic and rectal polyp cases, such as polyps &amp;gt;20mm, likely to be sessile, or difficult to remove endoscopically. The aim was to evaluate the effectiveness and clinical role of the SPEC MDT. Methods Data for patients discussed in SPEC MDT since its conception in January 2022 until September 2023 was retrospectively collected from the SPEC MDT database, a prospectively collected database. This included patient demographics, reason for referral, polyp characteristics and MDT outcomes. Results In 21 months, there have been 38 SPEC MDTs, with 355 cases discussed (average of 9 cases per MDT). There was at least one laparoscopic colorectal surgeon, gastroenterologist and a histopathologist in every MDT in accordance with BSG guidelines. Main referral reasons included endoscopy findings (72%) and re-discussion post-procedure (22%). Twenty-three patients had adenocarcinomas and three had NETs. MDT outcomes were EMR (23%), endoscopic surveillance (21%), clinic to discuss (no) surgery (19%), TAMIS (16%), urgent endoscopy (13%) or other (8%). Conclusion As the busiest Health Board in Wales for Colorectal Cancers, the formation of SPEC MDT has been an important step in improving the detection and treatment of advanced polyps and early cancers. Although too early to measure the impact on early cancer detection rates and improved decision making for these patients, formalising the MDT process in line with BSG guidelines has been an important step in improving the service offered to patients.

FP8.8 - LumenEye XI rigid digital rectoscope in the assessment of anorectal symptoms: a sustainable substitute for outpatient flexible sigmoidoscopy?

Abstract Aims To evaluate the acceptability, safety and diagnostic yield of the LumenEye XI in the assessment of anorectal symptoms. Methods Consecutive patients with anorectal symptoms, referred to the colorectal unit by their general practitioner, had a full clinical assessment followed by endoscopic examination using the LumenEye XI by a consultant colorectal surgeon. Results 59 consecutive patients,16 being male, were examined. The median age was 59 years (range 27-90). The main reported presenting complaints were rectal bleeding (n = 18, 21.4%), proctalgia (n = 10, 15.5 %), faecal incontinence (n=12, 14.3%), obstructive defaecation (n=7, 8.3%), anorectal swelling (n = 7, 8.3%), and mucous discharge (n = 2, 2.4%). The main findings were haemorrhoids (n= 18, 22.5%), rectal prolapse and rectocoele (n=14, 17.5%), and inflammatory conditions (proctitis, anal fistula, pouchitis) (n=4, 5%). One patient was diagnosed with rectal cancer. 19 patients (23.75%) had normal findings. 13 patients (22%) were referred for further investigations. Out of the 18 patients with rectal bleeding, 16 had a definitive diagnosis made with LumenEye. The diagnoses in patients with rectal bleeding were haemorrhoids (n=15, 53.6%), inflammation (n=4, 14.3%), prolapse (n=2, 7.1%), and ulceration (n=1, 3.6%). No cause could be identified in 2 of these patients. The rectosigmoid junction was visualised in all patients who had an intact rectum (57 out of 59 patients). All patients tolerated the procedure well, with no complications. Conclusions LumenEye XI is safe and well accepted by patients with good diagnostic accuracy. It therefore offers a potential solution to helping to relieve the endoscopy burden and enable cost savings by reducing the number of outpatient flexible sigmoidoscopies.

Development of a core descriptor set for parastomal hernia repair.

Parastomal hernia repair is a poorly evidenced area, with uncertainty around the optimum management. There is considerable heterogeneity within the patient cohort, and currently there is no standardization of patient descriptors in the reporting of parastomal hernia repair. The aim of this study was to develop a core descriptor set of key patient characteristics for patients undergoing surgical repair of a parastomal hernia for reporting in all parastomal hernia research. A longlist of descriptors was generated from a review of the existing literature. The longlist was discussed with patients with lived experience of parastomal hernia repair. Colorectal, general and hernia surgeons took part in a three-round international modified Delphi process using a nine-point Likert scale to rank the importance of descriptors. Items meeting predetermined thresholds were included in the final set and discussed and ratified at the consensus meeting. Seventy seven respondents completed round one, with 23 (29.8%) completing round three. Eighty six descriptors were rated across the three rounds, with 52 descriptors shortlisted. The consensus meeting ratified a final core descriptor set with 19 descriptors across eight domains: anatomy, contamination, disease, previous treatment, risk factors, symptoms, pathway and other hernia. The core descriptor set reflects characteristics that are important to surgeons when reporting on parastomal hernia repair. The use of this agreed core descriptor set may aid the reporting of future studies.

Assessment of Education and Management of Endometriosis Among Colorectal Surgeons and Residents

Study ObjectiveA To identify the type of endometriosis education and surgical training colorectal surgery residents are exposed to during training. b To determine the current surgical management of endometriosis among recently graduated colorectal surgeons and their level of comfort. DesignA qualitative cross-sectional study was performed. An anonymous questionnaire was emailed to colorectal surgery residents of 2023 and recent graduates for completion. Data was then extracted and analyzed from REDCap. A chi-square test was performed on the primary outcome variables. SettingA REDCap electronic survey was administered through email to each participant. PatientsAll colorectal surgery residents in 2023 and recent graduates from Colon and Rectal Surgery subspecialty from 2012 to 2022. InterventionsA 17-item anonymous questionnaire was sent via email through REDCap. Measurements and Main ResultsThe survey was completed by 70 participants. Most respondents (58.5%) did not receive formal education on bowel endometriosis. Forty percent of participants (28/70) did not feel they received adequate training for surgical management of bowel endometriosis. In terms of surgical exposure, 3.8% (2) responded they had been involved in >15 bowel endometriosis cases and 18 (25.7%) had been exposed to 1–5 cases during colorectal training. Factors that predicted feeling adequately trained in managing endometriosis included formal endometriosis education (OR 4.70, 95% CI 1.37−16.12, p-value .027) and surgical exposure during training (OR 4.38, 95% CI 1.18–16.26, p-value .014). Additionally, the number of cases exposed during training is highly correlated with feeling adequately trained. ConclusionMore than half of colorectal surgeons did not receive formal education on bowel endometriosis and the majority had only been exposed to 1–5 cases during their colorectal training. An overwhelming majority were interested in further education. This study highlights opportunities for improvement in the exposure to education and surgical management of endometriosis among colorectal surgery trainees.

Have changes in colorectal surgery training impacted on mortality in cancer patients? A retrospective cohort study of 51,562 procedures.

The aim of this study was to explore whether there were any differences in consultant colorectal surgeon training and adjusted 90-day postoperative colorectal cancer mortality rates (AMR). We undertook a retrospective analysis of outcomes data published on the Association of Coloproctology of Great Britain and Ireland (ACPGBI) website. A total of 51,562 procedures for patients in England diagnosed with large bowel cancer between 2010 and 2015, registered under 551 consultants were included. Consultants were split into two cohorts. The first group were the pre-Calman Trained Consultants (pre-CTr), who completed their training before 1998. The second group-the post-Calman Trained Consultants (post-CTr)-included those who received their Certificate of Completion of Training (CCT) under the Calman Training Principles (CTC, 1998-2007) and the Modernising Medical Careers Curriculum (MMC, 2008 and onwards). The outcome measure was an AMR. The pre-CTr cohort (n=84) consisted of 3.6% female colorectal consultants (n=3/84), whereas the post-CTr cohort (n=467) consisted of 14.3% female colorectal consultants (n=67/467) (p=0.006). In this cross-sectional analysis over 5 years, the average pre-CTr undertook a greater number of colorectal resections than their post-CTr peers: median procedures (interquartile range, IQR): 104 (59) vs 89 (57) respectively, p=0.008. The median AMR was significantly greater among pre-CTrs compared with post-CTrs, median AMR (IQR): 2.7% (2.0) vs 2.1% (2.9), p=0.022. These data indicate that the implementation of the MMC and Calman training principles for colorectal training is associated with a statistically lower AMR compared with other historical training periods. This merits further exploration.

Validity of task-specific metrics for assessment in perineal proctectomy.

Perineal proctectomy is a complex procedure that requires advanced skills. Currently, there are no simulators for training in this procedure. As part of our objective of developing a virtual reality simulator, our goal was to develop and validate task-specific metrics for the assessment of performance for this procedure. We conducted a three-phase study to establish task-specific metrics, obtain expert consensus on the appropriateness of the developed metrics, and establish the discriminant validity of the developed metrics. In phase I, we utilized hierarchical task analysis to formulate the metrics. In phase II, a survey involving expert colorectal surgeons determined the significance of the developed metrics. Phase III was aimed at establishing the discriminant validity for novices (PGY1-3) and experts (PGY4-5 and faculty). They performed a perineal proctectomy on a rectal prolapse model. Video recordings were independently assessed by two raters using global ratings and task-specific metrics for the procedure. Total scores for both metrics were computed and analyzed using the Kruskal-Wallis test. A Mann-Whitney U test with Benjamini-Hochberg correction was used to evaluate between-group differences. Spearman's rank correlation coefficient was computed to assess the correlation between global and task-specific scores. In phase II, a total of 23 colorectal surgeons were recruited and consensus was obtained on all the task-specific metrics. In phase III, participants (n = 22) included novices (n = 15) and experts (n = 7). There was a strong positive correlation between the global and task-specific scores (rs = 0.86; P < 0.001). Significant between-group differences were detected for both global (χ2 = 15.38; P < 0.001; df = 2) and task-specific (χ2 = 11.38; P = 0.003; df = 2) scores. Using a biotissue rectal prolapse model, this study documented high IRR and significant discriminant validity evidence in support of video-based assessment using task-specific metrics.

Combined Endoscopy-Laparoscopy Surgery: When and How to Utilize This Tool.

Combined endoscopic and laparoscopic surgery (CELS) has been used to resect colon polyps since the 1990s. These colon-sparing techniques, however, have not yet been widely adopted. With the evolution of technology in both diagnosing and treating colon cancer, colorectal surgeons should strive for a diverse and complete armamentarium through which they can best serve their patients. In this article, we hope to provide clarity on CELS by discussing three topics: (1) the history and fruition of CELS; (2) the techniques involved in CELS; and (3) the utility of CELS within different clinical scenarios. Our goal is to educate readers and stimulate consideration of CELS in select patients who might benefit greatly from these techniques.

Timing of Loop Ileostomy Closure Does Not Play a Pivotal Role in Terms of Complications-Results of the Liquidation of iLEOstomy (LILEO) Study.

Loop ileostomy is commonly performed by colorectal and general surgeons to protect newly created large bowel anastomoses. The optimal timing for ileostomy closure remains debatable. Defining the timing associated with the best postoperative outcomes can significantly improve the clinical results for patients undergoing ileostomy closure. The LILEO study was a prospective multicenter cohort study conducted in Poland from October 2022 to December 2023. Full data analysis involved 159 patients from 19 surgical centers. Patients were categorized based on the timing of ileostomy reversal: early (<4 months), standard (4-6 months), and delayed (>6 months). Data on demographics, clinical characteristics, and perioperative outcomes were analyzed for each group separately and compared. No significant differences were observed in length of hospital stay (p = 0.22), overall postoperative complications (p = 0.43), or 30-day reoperation rates (p = 0.28) across the three groups. Additional analysis of Clavien-Dindo complication grades was performed and did not show significant differences in complication severity (p = 0.95), indicating that the timing of ileostomy closure does not significantly impact perioperative complications or hospital stay. Decisions on ileostomy reversal timing should be personalized and should consider individual clinical factors, including the type of adjuvant oncological treatment and the preventive measures performed for common postoperative complications.

Feasibility of triple assessment of the anastomosis using an anastomotic checklist.

Colorectal cancer is the third most common cancer and the second highest cause of cancer mortality in Australia. Despite advances in colorectal surgery, anastomotic leak still occurs in low-risk patients and is a substantial cause of morbidity and mortality. Many operative strategies are used to assess anastomotic integrity such as an air leak test or intraoperative flexible sigmoidoscopy, however an objective anastomotic checklist is yet to be developed and studied. This study aims to develop a photodocumentary anastomotic specific checklist and determine its feasibility for implementation. Patients undergoing left sided colorectal resections with primary anastomosis without a de-functioning ileostomy were prospectively included between May 2021 and December 2022. A photographic checklist assessing anastomotic perfusion, integrity via either air test or endoscopic image, evidence of complete operative doughnut specimens and the assessment of tension was implemented. The feasibility of an anastomotic checklist was externally validated by four independent colorectal surgeons from Australia, New Zealand and United States of America. The anastomotic checklist was completed in 44 patients. Mean age was 62 years, with 43% male and mean BMI 28. Operations included high anterior resection (45%), low anterior resection (18%), ultra-low anterior resection (20%), reversal of Hartmann's (11%). Median length of stay was 4 days. Complications post operatively were documented in six patients with anastomotic leak in 2% and wound infection in 6.8%. Intraclass correlation coefficients were poor amongst all reviewers with air leak and tension having no inter-reviewer correlation. The introduction of an anastomotic checklist was a feasible tool to systematically assess and document anastomotic integrity. Unfortunately, with the small sample size there was significant discrepancy in inter-observer variability, and this led to poor correlation regarding which patients were typically high risk requiring a temporary ileostomy. Larger studies on the implementation of an anastomotic checklist will be needed to evaluate if it is an inherently feasible approach and if there is an effect on anastomotic leak.

Development of a new patient-reported outcome measure for complex cryptoglandular fistulas (20-Item complex cryptoglandular fistula questionnaire™): a qualitative study

BackgroundThere are limited tools to measure the burden of disease and effectiveness of medical/surgical interventions in patients with cryptoglandular fistulas. The aim of this study was to explore concepts that are relevant and important to patients with complex cryptoglandular fistulas (CCF) and to develop a patient-centred, disease-specific, patient-reported outcome measure (PROM) to assess symptom burden and impacts of CCF.MethodsA targeted literature review was conducted, followed by one-to-one telephone interviews with five colorectal surgeons (USA, n = 3; UK, n = 1; Spain, n = 1) and 20 US adult patients with CCF to inform the development of a conceptual model and a CCF-specific PROM. The targeted literature review informed the development of the preliminary conceptual model and identified a PROM in the literature that was used as a reference to generate the draft CCF-specific PROM. The colorectal surgeon interviews provided insights on the experience of patients with CCF to refine the conceptual model, formulate probing questions for use in patient interviews, and to develop the draft CCF-specific PROM. Patients’ descriptions of their experiences with symptoms and the impacts on their lives and evaluation of the draft CCF-specific PROM in concept elicitation and cognitive interviews were used to develop the final conceptual model and final CCF-specific PROM.ResultsTen symptoms (odour, pain during bowel movement, abscess, post-operative pain, discharge/drainage/leakage, anal/perianal pain, inflammation/swelling, skin irritation, bleeding and itchiness) and 11 impacts (discomfort, inability to exercise, embarrassment, difficulty sitting, worry about disease, adapted life to maintain hygiene, negatively impacted social life/isolation, inability to perform daily activities, reduced interest in sex, negatively impacted intimate relationships and negatively impacted mood) were reported as most salient by patients. The patient experience, clinician perspective, and literature review provided input to item generation. Evaluation of relevance and patient understanding through cognitive interviews with patients provided evidence for the content validity of the new patient-reported outcome measure: the 20-item Complex Cryptoglandular Fistula Questionnaire™ (CCFQ-20™).ConclusionThe CCFQ-20™ is a new clinician-guided, patient-validated, disease-specific patient-reported outcome measure that measures disease impact and quality of life in patients with CCF.

Learning Curve of Robotic-Assisted Low Anterior Resection for Low and Mid Rectal Cancer.

Objective: The aim of our study was to assess the learning curve of robotic assisted low anterior resection with diverting loop ileostomy (LARDLI) for low and mid rectal cancer performed by novice in robotic-assisted surgery colorectal surgeon in a public hospital with limited access to the robotic platform. Methods: A retrospective analysis of all low and mid rectal cancer robotic-assisted operations was conducted. All procedures were performed by a single surgeon with a once per week access to the Da Vinci® Si™ Surgical System, Intuitive Surgical Inc. Demographic, clinical, and pathological data were reviewed. The cumulative sum (CUSUM) analysis was utilized to analyze learning curve for operative time. Results: A total of 107 consecutive patients who underwent LARDLI for lower and mid rectal cancer between November 2011 and July 2020 were included in the analysis. The median patients' age was 65 (range, 32-85) years, 72% were males (n = 77), and 91% (n = 97) received neoadjuvant therapy. Median operative time was 295.5 (range, 180-551) minutes. The conversion rate was 3.7% (n = 4). Median length of hospital stay was 6 (range, 1-41) days. There were 35 (32.7%) postoperative complications, of these 7 (6.5%) were major complications (≥Grade 3, according to the Clavien-Dindo classification). There was only one intraoperative complication (.9%). CUSUM analysis showed that the learning curve was 49 cases to achieve a plateau. Conclusions: The learning curve of robotic assisted low anterior resection for lower and mid rectal cancer for a novice in robotic surgery colorectal surgeon with limited access to the robotic platform is 49 cases. Surgeon and operative team dedication, alongside sufficient hospital support, may lower the number of cases of the learning curve.

Prophylactic ureteral catheterization performed by the colorectal surgeon: a retrospective analysis

Prophylactic ureteral catheterization performed by the colorectal surgeon: a retrospective analysis