Search

Colon cancer resection can be technically difficult in the obese (OB) population. Robotic surgery is a promising technique but its benefits remain uncertain in OB patients. The aim of this study is to compare OB versus non-obese (NOB) patients undergoing robotic colon surgery, as well as OB patients undergoing robotic versus open or laparoscopic colonic surgery.A systematic review and meta-analysis was performed. Primary outcome measures included length of stay (LOS), surgical site infection (SSI) rate, complications, anastomotic leak and oncological outcomes.A total of eight studies were included, with five comparing OB and NOB patients undergoing robotic colon surgery included in meta-analysis. A total of 263 OB patients and 400 NOB patients formed the sample for meta-analysis. There was no significant difference between the two groups in operative time, conversion to open, LOS, lymph node yield, anastomotic leak and postoperative ileus. There was a trend towards a significant increase in overall complications and SSI in the OB group (32.3% OB versus 26.8% NOB for complications, 14.2% OB versus 9.9% NOB for SSI). The three included studies comparing surgical techniques were too heterogeneous to undergo meta-analysis.Robotic colon surgery is safe in obese patients, but high-quality prospective evidence is lacking. Future studies should report on oncological safety and the cost-effectiveness of adopting the robotic technique in these challenging patients.

Rectal cancer is a challenging disease process to manage, with a rising incidence in young adults. Several clinical advances have been made in the past decade with regards to optimal treatment strategies in early-stage (T1-2, node negative tumours) and locally advanced cancers (T3-4 and/or nodal positivity) utilizing a multimodal approach of surgery, neoadjuvant chemoradiotherapy, and adjuvant chemotherapy, all aiming to optimize oncological outcomes, while minimizing associated morbidity. This narrative review aimed to summarize trial level evidence apropos the management of early and locally advanced rectal cancer. All relevant prospective clinical trials were identified through a computer-assisted search of PubMed, EMBASE, Medline databases between 1990 and 30 June 2021. With regards to early rectal cancer, there is limited trial-level evidence in the literature. Total mesorectal excision (TME) is the current standard of care, but local excision could be considered in select patients with pT1 tumours, or patients with near or complete clinical response to neoadjuvant CRT. As for locally advanced rectal cancer, the current standard of care consists of long-course chemotheradiotherapy or short-course radiotherapy, followed by TME. However, the role of total neoadjuvant therapy is promising, with respect to both oncological outcomes, as well as in reducing toxicity. Both induction and consolidation chemotherapy treatment approaches have been described in literature, with encouraging early results. The optimal management of rectal cancer is constantly evolving. More research is needed to investigate the long-term oncological and functional outcomes following new multimodal therapies in the management of early-stage and locally advanced rectal cancer.

Background Small bowel obstruction (SBO) is a common general surgical presentation and there has been a shift towards non-operative management (NOM) for patients with previous abdominal surgery. Historically, exploratory surgery has been mandated for SBO in patients with a virgin abdomen. However, there is increasing evidence for NOM in this group of patients. Methods A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was undertaken between 1995 and 2020 on Ovid MEDLINE, EMBASE and PubMed. Primary outcome measures were success and failure rates, whereas secondary outcome measures were morbidity, mortality rates and identifying underlying aetiologies. Results Six observational studies were included, with 205 patients in the NOM and 211 patients in the operative group. There was a high success rate of 95.6% and low morbidity rate of 3.1% in the NOM group compared to 88.6% and 26% in the operative group, respectively. Both groups reported no mortalities. The most common aetiologies for SBO in a virgin abdomen were adhesions (63%), malignancy (11%), foreign body/bezoar (5%), internal hernia (4%) and volvulus (4%). Conclusion NOM for SBO is a safe and feasible option for a select group of clinically stable patients with a virgin abdomen without features of closed-loop obstruction. Adhesions are the most common cause of SBO in this group of patients. Further large-scale prospective clinical studies with standardized NOM modality, homogenous clinical resolution indicators and long-term follow-up data are warranted to allow for quantitative analysis to reinforce this evidence.

As coronavirus (COVID-19) cases continue to rise, healthcare workers have been working overtime to ensure that all patients receive care in a timely manner. Our study aims to identify the impact and outcomes of COVID-19 on colorectal cancers presentations across the five major colorectal units in Melbourne, Australia.This is a retrospective study from a prospectively collected database from the binational colorectal cancer audit (BCCA) registry, as well as inpatient records. All patients with colorectal cancer between Pre-COVID-19 period (1 July 2018-2030 June 2019) and COVID-19 period (1 July 2020-2030 June 2021) were compared. Benign pathology and other cancer types were excluded.A total of 1609 patients were included in the study (700 Pre-COVID-19 period, 906 COVID-19 period). During COVID-19 period, there was a higher proportion of emergency surgery (28.1% vs. 19.8%; P 0.001), a higher nodal (P = 0.024) and metastatic stage (P = 0.018) at presentation, but no increase in the rate of return to operating theatres (P = 0.240), inpatient death (P = 0.019) or 30-day readmission (P = 0.000). There was also no difference in the post-operative surgical complications (P = 0.118). Utility of neoadjuvant therapy did not increase during the pandemic (P = 0.613).The heightened measures in the healthcare system ensured CRC patients still received their surgery in a timely fashion. With the current rise in the new strain of COVID-19 (Omicron), we have to continue to come up with new strategies to provide timely access to CRC care.

Background Colorectal cancer resection in the obese (OB) patients can be technically challenging. With the increasing adoption of laparoscopic surgery, the benefits remain uncertain. Hence, the aim of this study is to assess the short- and long-term outcomes of laparoscopic compared to open colorectal cancer resection in the OB patients. Methods A systematic review and meta-analysis was performed according to the PRISMA guidelines. The outcome measures were 5-year disease-free survival, overall survival, circumferential resection margin and local and distant recurrence. Results A total of 20 studies were included, with a total number of 6779 participants, of whom 1785 (26.3%) were OB and 4994 (73.7%) were non-obese (NOB) participants. The OB patients had higher R1 resection (OB 6.9% versus NOB 3.1%; P = 0.011) and lower mean number of lymph nodes harvested, with standard mean difference of -0.29; P = 0.023, favouring the NOB patients. However, there was no statistical difference for local (OB 2.8% versus NOB 3.4%) or distant recurrence (OB 12.9% versus NOB 15.2%) rate between the two cohorts. There was no difference in 5-year disease-free survival (OB 81% versus NOB 77.4%; odds ratio 1.25, P = 0.215) and overall survival (OB 89.4% versus NOB 87.9%; odds ratio 1.16, P = 0.572). Lastly, the OB group had higher mean total blood loss, total operative time and length of hospital stay when compared to NOB patients. Conclusion From a pooled non-randomized study, laparoscopic colorectal cancer resection is safe in OB patients with equivalent long-term outcomes compared to NOB patients. However, there is a higher morbidity rate with an increased demand on hospital resources for the OB cohort.

BACKGROUND Anal intraepithelial neoplasia (AIN) is dysplasia in the epithelium of the anus and is a pre-malignant condition associated with a low rate of progression to invasive squamous cell carcinoma (SCC). The natural history of progression for AIN to anal SCC is poorly defined. This study aims to review our experience with AIN and investigate the natural history of progression. METHODS Data on all patients with AIN from January 2005 to December 2015 were retrospectively reviewed. Three separate databases were searched - Colorectal, Radiation Oncology and Infectious Diseases. All databases were cross-referred to obtain a complete but non-duplicated data set. Electronic charts were reviewed to obtain clinical information. RESULTS Twenty-eight patients were identified with AIN of various grades. There were 25 males, three females. Twenty of the male patients were human immunodeficiency virus (HIV) positive. Mean length of follow up was 56 months. Complete regression of AIN to normal was noted in 13 patients (46%). Four patients had persisting AIN III with no evidence of regression or malignant transformation. Nine patients with pre-existing AIN developed SCC (32%). Seven were positive for HIV infection (all males). Median time to progression was 36 months. None of the patients demonstrated clear linear pattern of progression of AIN to SCC. CONCLUSION High grade AIN may progress to anal SCC and surveillance is indicated. The exact natural history of progression for AIN is difficult to predict. There is no linear progression over time evident. HIV patients with AIN are at higher risk of developing SCC.

Background Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital. Methods A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re-fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period. Results A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra-abdominal surgery not related to bowel neoplasia (50%) and post intra-abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months. Conclusion Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.

Anal intraepithelial neoplasia (AIN) is dysplasia in the epithelium of the anus and is a pre-malignant condition associated with a low rate of progression to invasive squamous cell carcinoma (SCC). The natural history of progression for AIN to anal SCC is poorly defined. This study aims to review our experience with AIN and investigate the natural history of progression.Data on all patients with AIN from January 2005 to December 2015 were retrospectively reviewed. Three separate databases were searched - Colorectal, Radiation Oncology and Infectious Diseases. All databases were cross-referred to obtain a complete but non-duplicated data set. Electronic charts were reviewed to obtain clinical information.Twenty-eight patients were identified with AIN of various grades. There were 25 males, three females. Twenty of the male patients were human immunodeficiency virus (HIV) positive. Mean length of follow up was 56 months. Complete regression of AIN to normal was noted in 13 patients (46%). Four patients had persisting AIN III with no evidence of regression or malignant transformation. Nine patients with pre-existing AIN developed SCC (32%). Seven were positive for HIV infection (all males). Median time to progression was 36 months. None of the patients demonstrated clear linear pattern of progression of AIN to SCC.High grade AIN may progress to anal SCC and surveillance is indicated. The exact natural history of progression for AIN is difficult to predict. There is no linear progression over time evident. HIV patients with AIN are at higher risk of developing SCC.

Background Botulinum toxin (Botox) injection for chronic anal fissure (CAF) is commonly performed, yet there remains no consensus on optimal dosage or frequency of injections required to achieve complete resolution of anal fissure. The aim of this study was to determine the effectiveness of Botox and side-effect profile in the management of CAF. Methods A retrospective clinical study of patients between 2010 and 2014 who underwent a Botox injection for CAF at a tertiary centre was performed. The effectiveness of Botox was measured using standardized outcomes including overall healing rate, presence of anal pain, recurrence and need for repeat botulinum injection. Binary outcomes were assessed using logistic regression model. The analysis was performed using Stata version 13 (StataCorp, College Station, TX, USA). Results One hundred and one patients underwent 126 Botox injections within the study period. The mean first post-operative visit was at 1 month. The overall recurrence rate was 32%. The majority of patients were given 33 U. No statistically significant relationship between dose and recurrence was identified. The presence of pain at the first post-operative visit was a predictor of future recurrence (odds ratio 3.92, confidence interval 1.58–9.74, P = 0.003). Conclusion Botox is an effective strategy for CAF. Low doses can be given with good efficacy as highlighted by our audit and has the potential for great cost saving. The best predictor of recurrence is the presence of pain at the first post-procedure visit.

Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital.A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re-fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period.A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra-abdominal surgery not related to bowel neoplasia (50%) and post intra-abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months.Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.

Background This paper aimed to describe the training available and the process taken to establish a robotic colorectal surgery programme in a large Australian academic private hospital. Through this we hope to guide other surgeons and hospitals planning to introduce this technology in circumstances where such guidelines do not exist. Methods The available training and credentialing pathways are described, including the da Vinci Surgery Training Pathway provided by Intuitive Surgical and hospital-based supports. A proposed 9-point training and credentialing pathway is presented, along with the activities undertaken by each surgeon. Results From December 2011 to December 2013, 48 robotic colorectal procedures were performed at the Cabrini Hospital. Operations performed were as follows: 23 anterior resections, seven abdominoperineal resections, 11 rectopexies, three proctectomies and ileal pouch-anal anastomosis and four right hemicolectomies. There have been no conversions, and no major complications. There were no robot-specific complications. Conclusion We believe that this thorough and methodical approach to introducing robotics to colorectal surgery has been safe and effective, and should be applicable to other surgeons and hospitals wishing to introduce robotic technology to colorectal surgery.

Botulinum toxin (Botox) injection for chronic anal fissure (CAF) is commonly performed, yet there remains no consensus on optimal dosage or frequency of injections required to achieve complete resolution of anal fissure. The aim of this study was to determine the effectiveness of Botox and side-effect profile in the management of CAF.A retrospective clinical study of patients between 2010 and 2014 who underwent a Botox injection for CAF at a tertiary centre was performed. The effectiveness of Botox was measured using standardized outcomes including overall healing rate, presence of anal pain, recurrence and need for repeat botulinum injection. Binary outcomes were assessed using logistic regression model. The analysis was performed using Stata version 13 (StataCorp, College Station, TX, USA).One hundred and one patients underwent 126 Botox injections within the study period. The mean first post-operative visit was at 1 month. The overall recurrence rate was 32%. The majority of patients were given 33 U. No statistically significant relationship between dose and recurrence was identified. The presence of pain at the first post-operative visit was a predictor of future recurrence (odds ratio 3.92, confidence interval 1.58-9.74, P = 0.003).Botox is an effective strategy for CAF. Low doses can be given with good efficacy as highlighted by our audit and has the potential for great cost saving. The best predictor of recurrence is the presence of pain at the first post-procedure visit.

Background: Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity. The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit. Methods: The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001. Results: The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P

This paper aimed to describe the training available and the process taken to establish a robotic colorectal surgery programme in a large Australian academic private hospital. Through this we hope to guide other surgeons and hospitals planning to introduce this technology in circumstances where such guidelines do not exist.The available training and credentialing pathways are described, including the da Vinci Surgery Training Pathway provided by Intuitive Surgical and hospital-based supports. A proposed 9-point training and credentialing pathway is presented, along with the activities undertaken by each surgeon.From December 2011 to December 2013, 48 robotic colorectal procedures were performed at the Cabrini Hospital. Operations performed were as follows: 23 anterior resections, seven abdominoperineal resections, 11 rectopexies, three proctectomies and ileal pouch-anal anastomosis and four right hemicolectomies. There have been no conversions, and no major complications. There were no robot-specific complications.We believe that this thorough and methodical approach to introducing robotics to colorectal surgery has been safe and effective, and should be applicable to other surgeons and hospitals wishing to introduce robotic technology to colorectal surgery.

Aim: To compare patients having low Hartmann's resection (LHP) with abdominoperineal resection (APR) by investigating postoperative complications. Methods: Retrospective comparative analysis of preoperative state and postoperative course for patients having surgery from 1 January 1997 to 1 July 2001, by the surgeons of the Colorectal Unit, Christchurch Hospital, Christchurch, New Zealand. Results: Over a 54-month period 65 patients underwent either LHP or APR (29 LHP, 36 APR). The median age/sex (male:female) of patients for LHP was 76 years (51−90 years) (14:15), for APR 72 years (31−93 years) (19:17). The indication for surgery was predominantly cancer (LHP 89.6%, APR 94.4%). There was a high rate of preoperative comorbidities: LHP 75.9% (cardiac 62.1%, pulmonary 17.2%), APR 75% (cardiac 50%, pulmonary 15.9%). Preoperative chemoradiation was used in 10.3% of patients having LHP and 30.6% with APR. There was no difference in postoperative non-septic complications. There was a significant difference in the types of septic complications (P = 0.018), with a higher rate of pelvic abscesses after LHP (5). Perineal wound infection occurred in five patients having APR (14.3%). The median time to heal a perineal wound was 1 month (0.5−7 months). The median length of stay was 13 days for LHP (5−33 days) and 11 days for APR (6−19 days)(P = 0.0266). Conclusion: This non-randomized, retrospective, cohort study shows a surprisingly high rate of pelvic abscesses after LHP compared with APR. Perineal wound healing was a problem after APR, but less of a management problem than the septic complications after LHP. Both LHP and APR might be associated with significant morbidity. A high pelvic abscess rate following LHP is associated with a high likelihood of further surgical intervention and a prolonged length of stay.

Minimally invasive intestinal stoma formation using a laparoscopic approach or through a trephine, is widely described in published literature. The incidence of parastomal hernia (PH) following a stoma formed without formal laparotomy is not well reported. The present review aims to assess the current data available on minimally invasive stoma formation, with particular reference to the incidence of PH.A literature search using the Pubmed Medline database was performed, locating English language articles on minimally invasive stoma formation from 1970 to 2002. The manuscripts were searched manually for further references.The number of published studies describing laparoscopic stoma formation is small (263 stomas) and the follow-up studied were short (none longer than 1 year). The incidence of PH was 0-6.7%. The incidence following a trephine stoma was 6.7-12%, and the number of patients was small (118) and the follow up short (up to 12 months).The incidence of PH following minimally invasive stoma formation using a trephine or a laparoscopic technique remains unclear. Studies published to date are generally small and the follow up is short. A prospective randomized trial comparing minimally invasive stoma formation with stoma formation with laparotomy, is required.

Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity. The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit.The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001.The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P0.02). Multivariate analysis identified inguinal RLND (P = 0.002) and increasing tumour size (P = 0.045) as predictors of wound morbidity. More patients received postoperative radiotherapy after neck RLND compared to inguinal or axilla RLND (P = 0.03). Six (8%) patients developed local recurrence after lymphadenectomy. At a median follow up of 22 months, 34 (53%) patients have died, from disseminated disease.Radical lymphadenectomy for melanoma is associated with significant morbidity. Inguinal node dissection has a higher rate of complications than axillary dissection. Low local recurrence rates can be achieved, limiting the potential morbidity of uncontrolled regional metastatic disease.