Colorectal Surgery Practice Research Articles

Gastrointestinal functions after laparoscopic right colectomy with intracorporeal anastomosis: a pilot randomized clinical trial on effects of abdominal drain, prolonged antibiotic prophylaxis, and D3 lymphadenectomy with complete mesocolic excision

PurposeRoutine use of abdominal drain or prolonged antibiotic prophylaxis is no longer part of current clinical practice in colorectal surgery. Nevertheless, in patients undergoing laparoscopic right hemicolectomy with intracorporeal anastomosis (ICA), it may reduce perioperative abdominal contamination. Furthermore, in cancer patients, prolonged surgery with extensive dissection such as central vascular ligation and complete mesocolon excision with D3 lymphadenectomy (altogether radical right colectomy RRC) is called responsible for affecting postoperative ileus. The aim was to evaluate postoperative resumption of gastrointestinal functions in patients undergoing right hemicolectomy for cancer with ICA and standard D2 dissection or RRC, with or without abdominal drain and prolonged antibiotic prophylaxis.MethodsMonocentric factorial parallel arm randomized pilot trial including all consecutive patients undergoing laparoscopic right hemicolectomy and ICA for cancer, in 20 months. Patients were randomized on a 1:1:1 ratio to receive abdominal drain, prolonged antibiotic prophylaxis or neither (I level), and 1:1 to receive RRC or D2 colectomy (II level). Patients were not blinded. The primary aim was the resumption of gastrointestinal functions (time to first gas and stool, time to tolerated fluids and food). Secondary aims were length of stay and complications’ rate. ClinicalTrials.gov no. NCT04977882.ResultsFifty-seven patients were screened; according to sample size, 36 were randomized, 12 for each arm for postoperative management, and 18 for each arm according to surgical techniques. A difference in time to solid diet favored the group without drain or antibiotic independently from standard or RRC. Furthermore, when patients were divided with respect to surgical technique and into matched cohorts, no differences were seen for primary and secondary outcomes.ConclusionAbdominal drainage and prolonged antibiotic prophylaxis in patients undergoing right hemicolectomy for cancer with ICA seem to negatively affect the resumption of a solid diet after laparoscopic right hemicolectomy with ICA for cancer. RRC does not seem to influence gastrointestinal function recovery.

Does Operating Volume On-Call Vary by Surgeon? Analysis of On-Call Cases in an Academic Colorectal Practice.

The aim was to determine whether on-call case volumes differ amongst colorectal surgeons, and what cases are performed on-call in an academic colorectal surgery practice. The on-call schedule for the year 2021 of a colorectal surgery practice was analyzed. Details of the case origin and operative details were collected. Average cases performed per call per surgeon were compared. Ten surgeons were included, and average cases per call ranged from .5 to 1.4 with 1.0 the overall average (P = .007). Analyzing individual pairs, differences existed between the 2 busiest and the least busy on-call surgeon (both P < .05). Most patients operated on-call were admitted via the emergency department (59%), and the most common operations were exams under anesthesia (39%) and bowel resections (33%). On average, 1 on-call case was performed per day. Surgeon on-call volume was similar aside from the busiest and least busy on-call surgeons.

The role of endoluminal surgery in a colorectal surgical practice. A global view

Patients with large colorectal polyps or mucosal neoplasms not amenable to standard polypectomy have traditionally undergone colon resection. However, minimally invasive surgical techniques have gained popularity over the past two decades. Transanal approaches such as transanal endoscopic microsurgery and transanal minimally invasive surgery have enabled surgeons to treat mucosal neoplasms located in the rectum. Later on, robotic surgery was incorporated into the transanal approach. Meanwhile, there was no such treatment option for more proximal colonic neoplasms then, and endoscopic mucosal resection and endoscopic submucosal dissection emerged in Japan to provide resection in treating such proximal lesions. Nowadays, all procedures performed in a hollow organ integrating standard surgical (dissection, resection, suturing, homeostasis) and oncological principles (en-bloc resection, clean surgical margins) are merged under endoluminal surgery. Within the scope of this review, we aimed to elaborate an overview of the role of endoluminal surgery in daily colorectal surgery practice while focusing on endoscopic procedures.

How to adopt endoluminal surgery in a new colorectal surgery practice and endoluminal management of T1 colon cancers

Endoluminal surgery in colorectal surgery involves the removal of polyps/lesions using advanced colonoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Prior to the adoption of these techniques in a new colorectal surgery practice, a colorectal surgeon should have some mastery of basic colonoscopy skills along with colonoscopic polypectomy. There are a variety of training options to learn endoluminal surgery including industry and institutional based courses, observation of a master endoscopist, or observational experience in Japan. Adoption of these techniques in a new practice is facilitated by knowledge of what equipment is required and the availability of trained staff. Endoluminal management of T1 colon cancers is an acceptable method of treatment and an alternative to surgical resection provided that the proper parameters are met.

The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022

IntroductionPhysicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography. MethodsWe performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age. ResultsFrom 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+). ConclusionsColorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.

Development of a Standardized Process for Transition to Adult Care in a Pediatric Colorectal Surgery Clinic

BackgroundAs pediatric patients with colorectal diseases grow, it is important to address transition to adult practice. We aim to describe our center's transition process and early outcomes. MethodsWe developed a standardized process for transition to adult practice. An annual survey is given to parents and caregivers starting at age 12 that assesses knowledge of disease, independence with healthcare tasks, and confidence and interest regarding transition. After multidisciplinary review, those eligible are recommended for transition. Those not referred are provided with tools to help with areas of weakness. Outcomes were analyzed with descriptive and regression analyses (significance at p ≤ 0.05). ResultsA total of 116 patients were evaluated, with 80 patients (69.0%) recommended for transition. Median age at survey was 15.5 years [IQR: 13.7–18.1], and those recommended were older (16.6 years [IQR: 14.7–19.4] vs 13.5 years [IQR: 12.5–14.9], p < 0.001)). Primary diagnosis and gender were not associated with recommendation for transition. Overall, a minority (18.1%) were able to complete healthcare tasks; this correlated strongly with transition recommendation (26.3% vs 0.0%, p < 0.0001). On regression controlling for age, diagnosis, knowledge, and confidence, age (aOR 1.98, 95% CI 1.44–2.71) and confidence (aOR 3.78, 95% CI 1.29–11.11) independently predicted transition recommendation. ConclusionA standardized approach may be effective in transitioning patients from pediatric to adult colorectal surgery practice. Patients who transition are more confident and can perform healthcare tasks independently; however, these skills are not essential prior to a recommendation of transition. Level of evidenceIII.

Fibrin glue and coats compromise the integrity of colonic anastomosis: an experimental trial on rats.

Anastomotic leak remains a dreaded complication in colorectal surgery. Identifying optimal techniques that minimize its incidence is an active area of investigation. The aim of this experimental study was to evaluate the effect of commonly used hemostatic products on the integrity of colonic anastomoses. Male Wistar rats were randomized into 4 groups. In the control group (A), the anastomosis was performed using the standard hand-sewn technique in the ascending colon. In group B the hand-sewn technique was reinforced with a collagen-fibrinogen patch, in group C with fibrin glue, and in group D with a polyethylene glycol (PEG)-coated oxidized cellulose patch. On the 7th postoperative day, anastomotic bursting pressure measurements were obtained. A specimen surrounding the anastomosis was retrieved for histopathologic evaluation. Of the 19 rats, 17 survived and 15 were included in the analysis (5 in each of groups A, B and C). Testing in group D was discontinued following adverse events in the preliminary experiments. The mean bursting pressure of the anastomosis was significantly higher in the control group (A: 221±19.41 mmHg, B: 151±14.42 mmHg, and C: 112±13.57 mmHg; P=0.001). Anastomotic healing parameters were not different between groups. Although experimental data support the use of sealants in defective anastomoses, in this study the reinforcement of colonic anastomosis with fibrin or oxidized cellulose-PEG sealants did not improve either bursting pressure values or anastomotic healing. More data from robust anastomoses of animals and humans are needed before sealing becomes common clinical practice in colorectal surgery.

Colonoscopy withdrawal times and adenoma detection rates in a large, multi-site colorectal surgery practice.

433 Background: Colonoscopy withdrawal times (CWT) and adenoma detection rates (ADR) have been extensively correlated in medical literature. The American College of Gastroenterology (ACG) 2021 guidelines recommend measuring quality indicators for screening colonoscopy that achieve minimum benchmarks for ADR (&gt;=25%) and CWT (&gt;=6 minutes). In October 2022, M Desai et al reported in a sample of 1142 patients (46% screening and 54% surveillance), ADR increased as withdrawal time increased from 6 to 13 minutes. Results demonstrated a 6% increase per minute in the likelihood of detecting an additional patient with at least 1 adenoma. Texas Colon and Rectal Specialists routinely reviews ADR’s and CWT’s. This retrospective descriptive study presents a concise review of the correlation between CWT’s and ADR’s in a homogenous set of screening and surveillance patients. Methods: We examined 7164 abstracted colonoscopy records from 31 colorectal surgeons. Diagnostic colonoscopies were excluded. We studied patients between 45 and 84 years of age at the time of the colonoscopy. Each patient was noted for the colonoscopy CWT as well as whether at least one adenomatous polyp was detected. These data were reported in a scatter plot of ADR over CWT as well as a bubble chart of ADR over CWT by each surgeon. A two-sample t-test confirmed a statistical difference between the mean CWT of the adenoma-positive patients and those that were not positive. Results: Consistent with the literature, ADR increased with CWT. The mean CWT was 14.2 minutes in the group where an adenoma was detected (n=3289) and 10.6 minutes in the group where an adenoma was not detected (n=3875), (p&lt;0.05 and CI of 95%). Mean CWT was 12.3 minutes, mode was 7 minutes, median was 10.25 minutes, and the mean ADR was 45.9%. The best ADR performance was 62.5% at a mean of 26.8 minutes CWT and the worst performance was 27.7% at 10 minutes CWT. A bubble chart demonstrates the relationship between CWT and ADR by surgeon with the bubbles representing individual colonoscopy volumes. Consistent with the literature, ADR increased with CWT. The mean CWT was 14.2 minutes in the group where an adenoma was detected (n=3289) and 10.6 minutes in the group where an adenoma was not detected (n=3875), (p&lt;0.05 and CI of 95%). Mean CWT was 12.3 minutes, mode was 7 minutes, median was 10.25 minutes, and the mean ADR was 45.9%. The best ADR performance was 62.5% at a mean of 26.8 minutes CWT and the worst performance was 27.7% at 10 minutes CWT. Conclusions: Our data indicate a significant relationship between CWT and ADR, and may suggest that CWT well beyond six minutes may yield better ADR’s. Furthermore, scope volume appears to play a role in the achievement of higher ADR’s, though this would require further investigation for optimal CWT, minimum expected ADR, optimal techniques and bowel prep, and emerging assistive technology.

FTP3.2 Differences in the Acute Phase Response in Right-Sided Colorectal Surgery: Evaluation of the Kono-S Anastomosis

Abstract Aims CRP monitoring has become routine post-operative practice in resectional colorectal surgery and is useful as a predictive tool for identification of anastomotic leak. Day 3 CRP &amp;gt; 150 has been shown to be highly predictive of anastomotic leak. The acute phase response observed in surgery for Crohn’s disease (CD) is often more pronounced compared to malignancy and this is not accounted for in post-operative monitoring. This study looks at the difference in CRP in patients undergoing right hemicolectomy for cancer versus CD and evaluates any difference in CD patients who have conventional versus Kono-S anastomosis. Methods A single-center retrospective analysis of patients undergoing right hemicolectomy for malignancy and CD was undertaken, including CD patients with conventional and Kono-S anastomosis. Primary outcomes included CRP on Day 1 and 3 post-surgery. Length of stay, leak rate and post-operative infections were recorded. Analyses were carried out including and excluding patients with post-operative leak and infection. Results Day 1 CRP was significantly higher in patients undergoing surgery undergoing surgery for CD compared to malignancy (p &amp;lt;0.001). Day 3 CRP was significantly higher in patients undergoing surgery for CD compared to malignancy (p = 0.017). There was no significant difference between CD patients undergoing surgery with Kono-S anastomosis compared to conventional anastomosis. Kono-S anastomosis was not associated with any difference in leak, infection, or length of stay. Conclusions The rise in post-operative CRP is more pronounced in CD patients compared to cancer patients. CD patients with Kono-S anastomosis do not have significantly different post-operative CRP from patients with conventional anastomoses.

What Every Colorectal Surgeon Needs to Know About Colorectal Surgery Practice and the American Medical Association.

Mongiu, Anne M.D., Ph.D.1; Tyler, Kelly M.D.2; On behalf of the Healthcare Economics Committee of the American Society of Colon and Rectal Surgeons Author Information

Effect of a Patient Blood Management system on perioperative transfusion practice and short-term outcomes of colorectal cancer surgery.

Patients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes. This study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015-2017) and the post-PBM (2018-2020) periods. A total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation. The PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.

Colorectal Surgery Practice, Training, and Research in Low-Resource Settings.

Colorectal surgery (CRS) practice, training, and research differ between low- and middle-income countries (LMICs) and high-income countries due to disparity in resources. LMIC CRS is primarily done by general surgeons due to the paucity of fully trained colorectal surgeons. The majority of colon and rectal resections are done using open techniques, and laparoscopy and robotic platforms are only available in select private or academic centers. Multi-disciplinary teams are not available in most hospitals, so surgeons must have a broad knowledge base, and learn to adapt their practice. Formal CRS training opportunities through accredited post-residency fellowships and professional colorectal surgical associations are limited in LMICs. CRS is less established as an academic field, and less data are generated in LMICs. There are fewer staff and less dedicated funding for CRS research. However, LMIC colorectal surgeons and researchers can contribute valuable clinical findings especially on conditions of higher prevalence in their settings such as anal squamous cell carcinoma and obstetric fistulas. Effective surgical care for colorectal conditions requires significant investment in infrastructure, training, and governance in LMICs. This is critical to improve access to safe surgical care for all.

TU2.12 Experience of Elective Colorectal Cancer Surgery at District General Hospital (DGH): Single centre study

Abstract Background Elective colorectal resection surgery is one of the most common surgical procedures performed for bowel cancer treatment. This study evaluates the whole practice of colorectal cancer surgery in a DGH in England. Aims The primary outcome is to measure postoperative length of stay (LOS), with secondary outcomes including approach of surgical operation and conversion rate, R0 resection, VTE prophylaxis and its compliance with NICE guidelines, postoperative DVT over a period of one year, readmission rate within 30 days of discharge and reasons for readmission. Methods A single centre, retrospective, observational study was performed over a period of a year from January 2018 –January 2019. Patients were eligible for study inclusion if they had undergone planned surgical resection for colorectal cancer after being discussed in the local colorectal cancer MDT. Results A total of 123 patients were included. Mean length of stay was 7.97 days. 74.7% of the procedures were performed by laparoscopic approach with conversion rate of 6.5%. R0 resection was achieved in 95.1%. 96.7% of patients who underwent surgery for colorectal cancer received extended VTE prophylaxis as per NICE guidelines. Six patients had developed post-operative DVT and one inpatient death recorded. 13.8% of patients that underwent colorectal surgery for cancer were readmitted within 30 days of discharge. SBO, abdominal/pelvic collection, wound dehiscence and SSI as the most common reasons for readmission. Conclusion Laparoscopic approach is the preferred method for elective colorectal resection surgeries with acceptable measures of patient outcome including R0 resection, postoperative length of stay, DVT and readmission rate.

Modern Machine Learning Practices in Colorectal Surgery: A Scoping Review

Objective: The use of machine learning (ML) has revolutionized every domain of medicine. Surgeons are now using ML models for disease detection and outcome prediction with high precision. ML-guided colorectal surgeries are more efficient than conventional surgical procedures. The primary aim of this paper is to provide an overview of the latest research on “ML in colorectal surgery”, with its viable applications. Methods: PubMed, Google Scholar, Medline, and Cochrane library were searched. Results: After screening, 27 articles out of 172 were eventually included. Among all of the reviewed articles, those found to fit the criteria for inclusion had exclusively focused on ML in colorectal surgery, with justified applications. We identified existing applications of ML in colorectal surgery. Additionally, we discuss the benefits, risks, and safety issues. Conclusions: A better, more sustainable, and more efficient method, with useful applications, for ML in surgery is possible if we and data scientists work together to address the drawbacks of the current approach. Potential problems related to patients’ perspectives also need to be resolved. The development of accurate technologies alone will not solve the problem of perceived unreliability from the patients’ end. Confidence can only be developed within society if more research with precise results is carried out.

Early experience with focused telemedicine implementation in an academic colorectal surgery practice

BackgroundThe need to continue providing care to patients during the corona virus disease 2019 pandemic facilitated telemedicine’s rapid adoption, including in surgical clinic settings. Our purpose was to evaluate integration of telemedicine into an academic colorectal surgery practice and assess physician experiences providing telemedicine care. MethodsPatients seen in colorectal surgery clinic by telemedicine and in person from March 31, 2020 to August 31, 2020 were evaluated. Demographic and clinical outcomes were assessed for patients. Physician responses to a survey were collected. ResultsTwo hundred and thirty-one telemedicine visits were performed by 4 physicians, comprising 20% of visits during the study period. Patients were 47.6% male and 90.9% Caucasian. In addition, 85.7% were established patients and 21.2% were postoperative visits. Diagnoses evaluated by telemedicine included benign and malignant anorectal and colorectal disease as well as inflammatory bowel disease. All providers reported being able to provide adequate care via telemedicine and were planning to continue providing telemedicine. Patients seen via telemedicine were more likely to be Caucasian and less likely to be African American (P < .001) and more likely to be established patients than those seen in person (P < .001). ConclusionDuring the COVID-19 pandemic, telemedicine was most successfully used to facilitate care for established patients, particularly the long-term care of colorectal cancer and inflammatory bowel disease. We identified significant differences in ethnicity between patients seen via telemedicine and those seen in person. Telemedicine represents an exciting advancement in patient care, although ongoing study is required regarding providing access to this technology to all colorectal surgery patients, particularly minority populations.

Surgical site infection prevention bundle in elective colorectal surgery

Surgical Site Infections (SSIs) are responsible for a significant economic burden as well as intangible costs suffered by the patient, with up to 60% deemed preventable. Colorectal patients are disproportionally affected by SSI due the risk of wound contamination with bowel content. We aimed to reduce the rate of superficial SSI after elective colorectal surgery using a bundle of evidence-based interventions. An SSI prevention bundle was implemented in elective colorectal surgery, comprised of triclosan-coated sutures, 2% chlorhexidine skin preparation and use of warmed carbon dioxide (CO2) during laparoscopic procedures. The SSI reduction strategy was prospectively implemented and compared with historical controls. Our primary outcome measure was the overall rate of superficial SSI. Centres for Disease Control and Prevention criteria, which use microbiological evidence in conjunction with clinical features were used as the definition of SSI. The overall SSI rate was 27.4% in the pre-bundle group (N= 208) and 12.5% in the patients who received the SSI prevention bundle (N= 184) (adjusted odds ratio 0.38; confidence interval 0.21-0.67; P<0.001). The median time to SSI diagnosis was postoperative day 8. Overall patient length of stay (LOS) was unchanged from six days at baseline following implementation of the bundle. We have shown successful implementation of an SSI prevention bundle which has reduced superficial SSI rate. We recommend this SSI prevention bundle becomes standard practice in elective colorectal surgery and plan to extend the bundle to emergency general surgery.

The ALLEGRO trial: a placebo controlled randomised trial of intravenous lidocaine in accelerating gastrointestinal recovery after colorectal surgery

BackgroundReturn of gastrointestinal (GI) function is fundamental to patient recovery after colorectal surgery and is required before patients can be discharged from hospital safely. Up to 40% of patients suffer delayed return of GI function after colorectal surgery, causing nausea, vomiting and abdominal discomfort, resulting in longer hospital stay. Small, randomised studies have suggested perioperative intravenous (IV) lidocaine, which has analgesic and anti-inflammatory effects, may accelerate return of GI function after colorectal surgery. The ALLEGRO trial is a pragmatic effectiveness study to assess the benefit of perioperative IV lidocaine in improving return of GI function after elective minimally invasive (laparoscopic or robotic) colorectal surgery.MethodsUnited Kingdom (UK) multi-centre double blind placebo-controlled randomised controlled trial in 562 patients undergoing elective minimally invasive colorectal resection. IV lidocaine or placebo will be infused for 6–12 h commencing at the start of surgery as an adjunct to usual analgesic/anaesthetic technique. The primary outcome will be return of GI function.DiscussionA 6–12-h perioperative intravenous infusion of 2% lidocaine is a cheap addition to usual anaesthetic/analgesic practice in elective colorectal surgery with a low incidence of adverse side-effects. If successful in achieving quicker return of gut function for more patients, it would reduce the rate of postoperative ileus and reduce the duration of inpatient recovery, resulting in reduced pain and discomfort with faster recovery and discharge from hospital. Since colorectal surgery is a common procedure undertaken in every acute hospital in the UK, a reduced length of stay and reduced rate of postoperative ileus would accrue significant cost savings for the National Health Service (NHS).Trial registrationEudraCT Number 2017-003835-12; REC Number 17/WS/0210 the trial was prospectively registered (ISRCTN Number: ISRCTN52352431); date of registration 13 June 2018; date of enrolment of first participant 14 August 2018.

A Survey on the Practice of Enhanced Recovery After Elective Colorectal Surgery in Western Australia

Background: Enhanced Recovery After Surgery (ERAS) is a 24-item multidisciplinary questionnaire program designed to optimize the patient's perioperative care to reduce postoperative morbidity. However, its adoption remains largely influenced by region and the institution and surgeons' personal judgement. Objectives: This study aims to evaluate the practice of ERAS in elective colorectal surgery in Western Australia through a survey. Design: Prospective survey. Setting: The survey was sent to all surgeons identified to be performing routine elective colorectal surgery in Western Australia. Patients and Methods: A questionnaire was designed based on the latest ERAS guidelines, consisting of questions on the demographics of the surgeons, annual number of major colorectal resections, and on various aspects of pre-, intra- and postoperative practices. The questionnaire was sent through email or handed to the surgeons in August 2020 for a period of 2 months. Sample Size: Twenty-four eligible surgeons participated in the survey. Main Outcome Measures: The main outcome was to investigate the areas of agreement and difference in ERAS practice in elective colorectal surgery in Western Australia. Results: Twenty of the 24 eligible surgeons (83.3%) completed the questionnaire. Among these, 65% surgeons perform &gt;50 major colorectal resections annually. There is a high agreement of the practice in certain areas: 70% surgeons perform &gt;50% of their cases laparoscopically; they do not routinely use nasogastric tubes, majority of the surgeons do not routinely place drains after right (95%) and left (70%) colonic surgeries, 75% surgeons are guided by the Acute Pain Service for postoperative analgesia, and 95% surgeons encourage early mobilization. A few areas of practice remain widely variable: preoperative mechanical bowel preparation, postoperative fluids and electrolytes, and assessment of gut function. Conclusion: This survey provides a snapshot of the practice of ERAS in elective colorectal surgery in Western Australia. While certain aspects are considered as universal practice, there are some gaps and barriers to implementation that need to explored further. Limitations: The survey did not classify questions into open or laparoscopic surgery, and some surgeons worked both in public and private institutions, where practices may differ.

Variations in colorectal cancer surgery practice across the United Kingdom during the COVID-19 pandemic – ‘Every land has its own law’

BackgroundIn March 2020 NHS England issued guidelines recognizing the elective component of cancer surgeries may be ‘curtailed’, due to staffing and supply shortages during the COVID-19 pandemic. However, it suggested, ‘local solutions’ should be sought in order to protect the delivery of cancer services.We aimed to compare surgeons’ practice for the provision of colorectal (CR) cancer surgery across the United Kingdom (UK), against updated Joint Royal Colleges & ACPGBI guidelines and highlight differences in practice, if any. MethodAn online survey was conducted. It examined surgical practice across the UK against current protocols for CR cancer surgeries, during the COVID-19 pandemic. Results29 individual responses were received from 23 NHS Trusts across the UK. 23/29 (79%) surgeons ceased or experienced delays in their CR cancer surgeries during the pandemic, with 3/29 (10%) yet to reintroduce these services. 19/26 (73%) surgeons instructed their patients to self-isolate prior to surgery, of which 5/19 (26%) correctly enforced a duration of 14 days. 10/19 (53%) participants adhered to guidelines of performing a CT chest within 24 h of surgery. 10/26 (38%) participants believe their patients are experiencing longer hospital admissions in the COVID-19 setting. ConclusionThis snap shot survey highlights the dramatic variations in CR cancer surgery practice within the UK and inconsistent adherence to protocols. Guidelines will no doubt change as our knowledge of COVID-19 increases both nationally and internationally. It is essential CR surgeons keep up to date with changes in guidance, so uniformity in practice can be maintained.

The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey

Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.