18 research outputs found
The Mesentery in Robot-Assisted Total Mesorectal Excision
No full textIn recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed
A case of cystic adventital disease of the popliteal artery demonstrated by magnetic resonance imaging
No full textPostponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study
No full textBackground: Right-sided obstructing colon cancer is most often treated with acute resection. Recent studies on right-sided obstructing colon cancer report higher mortality and morbidity rates than those in patients without obstruction. The aim of this study is to retrospectively analyse whether it is possible to optimise the health condition of patients with acute right-sided obstructing colon cancer, prior to surgery, and whether this improves postoperative outcomes. Method: All consecutive patients with high suspicion of, or histologically proven, right-sided obstructing colon cancer, treated with curative intent between March 2013 and December 2019, were analysed retrospectively. Patients were divided into two groups: optimised group and non-optimised group. Pre-operative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression. Results: In total, 54 patients were analysed in this study. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. Scheduled surgery was performed after a median of eight days (IQR 7–12). Postoperative complications were found in twelve (50%) patients in the optimised group, compared to twenty-three (77%) patients in the non-optimised group (p = 0.051). Major complications were diagnosed in three (13%) patients with optimisation, compared to ten (33%) patients without optimisation (p = 0.111). Postoperative in-hospital stay, 30-day mortality, as well as primary anastomosis were comparable in both groups. Conclusion: This pilot study suggests that pre-operative optimisation of patients with obstructing right sided colonic cancer may be feasible and safe but is associated with longer in-patient stay.</p
A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer
No full textBackground: Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC. Methods: A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to “colon tumour,” “stenosis or obstruction and surgery,” and “decompression or stents.” All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival. Results: Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19–54%) after emergency resection, and 30% (range 7–44%) after staged treatment. The average mortality rate was 7.2% (range 0–14.5%) after emergency resection and 1.2% (range 0–6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments. Conclusions: The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection
Impact of minimal invasive surgery techniques on long-term health-related quality of life in rectal cancer:a Dutch cohort study
No full textObjective: Limited data exists on health-related quality of life (HRQoL) after robot-assisted surgery (RAL) for rectal cancer beyond one-year post-surgery. This study compares long-term HRQoL following RAL total mesorectal excision (TME) to conventional laparoscopic (CL) TME. Methods: All rectal carcinoma patients from the 63-center Prospective National CRC cohort (PLCRC) who completed pre- and post-operative HRQoL questionnaires (EQ-5D, QLQ-C30, and QLQ-CR29) were retrospectively included. Delta scores per parameter were calculated by subtracting pre-operative scores from scores at one year. Sensitivity analysis included all patients with beyond one-year post-operative questionnaires, regardless of a pre-operative questionnaire. Data were analyzed using multivariate linear regression. Results: Patients undergoing RAL TME more often had low rectal tumors, more post-operative complications and more stomas. In patients with both pre- and post-operative questionnaires, no significant differences were found in the EQ-5D delta score (n = 591). The QLQ-C30 (n = 709) showed statistically significant and clinical relevant difference in fatigue favored CL TME (4.4 ± 1.9, p = 0.021). The QLQ-CR29 (n = 696) showed small, statistically significant differences favoring RAL in body image and stoma-related issues, but no clinical relevance. Sensitivity analysis EQ-5D (n = 1250), QLQ-C30 (n = 1423) or QLQ-CR29 (n = 1453) showed no clinically relevant differences. Conclusion: This is the first study comparing long-term HRQoL between CL and RAL surgery for rectal cancer. Although several statistically significant differences were found, no clinically relevant differences were observed except for a small difference in the subdomain fatigue of the EORTC QLQ-C30 favoring CL surgery. Furthermore, the current study underlines the relevance of a pre-operative HRQoL assessment.</p
Robot-Assisted Total Mesorectal Excision Versus Laparoscopic Total Mesorectal Excision: A Retrospective Propensity Score–Matched Cohort Analysis in Experienced Centers
No full textBACKGROUND: The superiority of robot-assisted over laparoscopic total mesorectal excision has not been proven. Most studies do not consider the learning curve while comparing the surgical technique.OBJECTIVE: This study aims to compare laparoscopic with robot-assisted total mesorectal excision performed by surgeons who completed the learning curve of the technique.DESIGN: This is a multicenter retrospective propensity score-matched analysis.SETTINGS: The study was performed in 2 large, dedicated robot-assisted hospitals and 5 large, dedicated laparoscopic hospitals.PATIENTS: Patients were included if they underwent a robot-assisted or laparoscopic total mesorectal excision for rectal cancer with curative intent at a dedicated center for the minimally invasive technique between January 1, 2015, and December 31, 2017.INTERVENTIONS: We compared robot-assisted with laparoscopic total mesorectal excision.MAIN OUTCOME MEASURES: The main outcome was conversion to laparotomy during surgery. Secondary outcomes were postoperative morbidity and positive circumferential resection margin.RESULTS: A total of 884 patients were included and, after matching, 315 patients per treatment group remained. Conversion was similar between laparoscopic and robot-assisted total mesorectal excision (4.4% vs 2.5% (p = 0.20)). Positive circumferential resection margin was equal (3.2% vs 4.4% (p = 0.41)). Overall morbidity was comparable as well, although a lower rate of wound infections was observed in the robot-assisted group (5.7% vs 1.9% (p = 0.01)). More primary anastomoses were constructed in the robot-assisted group (50.8% vs 68.3% (p < 0.001)). Finally, more open procedures were performed in dedicated laparoscopic centers, with an overrepresentation of cT4N+ tumors in this group.LIMITATIONS: This is a retrospective multicenter cohort; however, propensity score matching was applied to control for confounding by indication.CONCLUSIONS: Robot-assisted and laparoscopic total mesorectal excision are equally safe in terms of short-term outcomes. However, with the robot-assisted approach, more primary anastomoses were constructed, and a lower wound infection rate was observed. See Video Abstract at http://links.lww.com/DCR/B677.</p
Preoperative oral antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery: results from a before-after study
No full textBackground. Surgical site infections (SSIs) are common complications after colorectal procedures and remain an important source of morbidity and costs. Preoperative oral antibiotic prophylaxis is a potential infection control strategy, but its effectiveness without simultaneous use of mechanical bowel preparation (MBP) is unclear. In this study, we aimed to determine whether preoperative oral antibiotics reduce the risk of deep SSIs in elective colorectal surgery. Methods. We performed a before-after analysis in a teaching hospital in the Netherlands. Patients who underwent surgery between January 2012 and December 2015 were included. On 1 January 2013, oral antibiotic prophylaxis with tobramycin and colistin was implemented as standard of care prior to colorectal surgery. The year before implementation was used as the control period. The primary outcome was a composite of deep SSI and/or mortality within 30 days after surgery. Results. Of the 1410 patients, 352 underwent colorectal surgery in the control period and 1058 in the period after implementation of the antibiotic prophylaxis. We observed a decrease in incidence of the primary endpoint of 6.2% after prophylaxis implementation. When adjusted for confounders, the risk ratio for development of the primary outcome was 0.58 (95% confidence interval, 0.40-0.79). Other findings included a decreased risk of anastomotic leakage and a reduction in the length of postoperative stay. Conclusions. Preoperative oral antibiotic prophylaxis prior to colorectal surgery is associated with a significant decrease in SSI and/or mortality in a setting without MBP. Preoperative oral antibiotics can therefore be considered without MBP for patients who undergo colorectal surgery
Uptake of robot-assisted colon cancer surgery in the Netherlands
No full textBackground:The robot-assisted approach is now often used for rectal cancer surgery, but its use in colon cancer surgery is less well defined. This study aims to compare the outcomes of robotic-assisted colon cancer surgery to conventional laparoscopy in the Netherlands. Methods: Data on all patients who underwent surgery for colon cancer from 2018 to 2020 were collected from the Dutch Colorectal Audit. All complications, readmissions, and deaths within 90 days after surgery were recorded along with conversion rate, margin and harvested nodes. Groups were stratified according to the robot-assisted and laparoscopic approach. Results:In total, 18,886 patients were included in the analyses. The operative approach was open in 15.2%, laparoscopic in 78.9% and robot-assisted in 5.9%. The proportion of robot-assisted surgery increased from 4.7% in 2018 to 6.9% in 2020. There were no notable differences in outcomes between the robot-assisted and laparoscopic approach for Elective cT1-3M0 right, left, and sigmoid colectomy. Only conversion rate was consistently lower in the robotic group. (4.6% versus 8.8%, 4.6% versus 11.6%, and 1.6 versus 5.9%, respectively).Conclusions: This nationwide study on surgery for colon cancer shows there is a gradual but slow adoption of robotic surgery for colon cancer up to 6.9% in 2020. When comparing the outcomes of right, left, and sigmoid colectomy, clinical outcomes were similar between the robotic and laparoscopic approach. However, conversion rate is consistently lower in the robotic procedures.</p
Sexual, marital, and general life functioning in couples coping with colorectal cancer : A dyadic study across time
No full textObjectives This study evaluated the following: (a) levels of sexual, marital, and general life functioning for both patients and partners; (b) interdependence between both members of the couple; and (c) longitudinal change in sexual, marital, and general life functioning and longitudinal stress-spillover effects in these three domains from a dyadic perspective. Methods Couples (n = 102) completed the Maudsley Marital Questionnaire preoperatively and 3 and 6 months postoperatively. Mean scores were compared with norm scores. A multivariate general linear model and a multivariate latent difference score - structural equation modeling (LDS-SEM), which took into account actor and partner effects, were evaluated. Results Patients and partners reported lower sexual, mostly similar marital, and higher general life functioning compared with norm scores. Moderate to high within-dyad associations were found. The LDS-SEM model mostly showed actor effects. Yet the longitudinal change in the partners' sexual functioning was determined not only by their own preoperative sexual functioning but also by that of the patient. Preoperative sexual functioning did not spill over to the other two domains for patients and partners, whereas the patients' preoperative general life functioning influenced postoperative change in marital and sexual functioning. Health care professionals should examine potential sexual problems but have to be aware that these problems may not spill over to the marital and general life domains. In contrast, low functioning in the general life domain may spill over to the marital and sexual domains. The interdependence between patients and partners implies that a couple-based perspective (e.g., couple-based interventions/therapies) to coping with cancer is needed.</p
Evaluation of Short-Term Postoperative Outcomes of Lateral Lymph Node Dissection After Neoadjuvant Radiotherapy for Rectal Cancer Patients:The Early Learning Phase After Surgical Training in the Netherlands
No full textBackground: Distal, locally advanced rectal cancer might spread to lateral lymph nodes (LLNs), posing a risk of lateral local recurrence (LLR). This study evaluated quality-controlled implementation of lateral lymph node dissection (LLND) in the Netherlands. Methods: This retrospective multicenter cohort study included consecutively treated rectal cancer patients who underwent neoadjuvant therapy, total mesorectal excision (TME) surgery, and nerve-sparing minimally invasive LLND by trained surgeons across 10 Dutch hospitals. Training involved cadaver sessions, monthly video meetings, and proctoring. Outcome measures included intra- and postoperative complications, urogenital dysfunction and 18-month LLR, local recurrence (LR), and disease-free survival (DFS). Results: The study comprised 41 patients (median follow-up period, 16 months; interquartile range, IQR, 8–21 months) with advanced tumors (27% cT4, 49% cN2, 7% cM1), and a mean LLN size of 11 mm on primary-staging MRI. Abdominoperineal resection was performed for 29 patients (70%). A beyond TME procedure was performed for 11 patients (28%). The median blood-loss was 250 ml (IQR, 100–400 ml), with obturator nerve injury reported in one patient. Malignant LLNs were found in 41% of the LLND specimens. Complications occurred for 22 patients (54%), 21% (9/41) of which were grade 3 or higher. Nine patients (22%, four of whom underwent beyond TME surgery) had a Foley or intermittent urinary catheter at the end of the follow-up period. Sexual dysfunction of three patients was reported. No ipsilateral LLRs occurred. The 18-month LR rate was 14%, and the DFS was 55%. Conclusion: Minimally invasive nerve-sparing LLND by trained Dutch surgeons showed acceptable complication rates and good oncologic control of the lateral compartment to date.</p
