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Purpose: To investigate functional outcomes and quality of life (QoL) after restorative proctocolectomy (RPC) using transanal minimal invasive surgery (TAMIS). Method: The study consists of two sub-studies. A cohort study comprised 98 consecutive patients, who underwent TAMIS RPC. These patients were the first at our department to undergo TAMIS RPC. We collected information about surgery, complications, postoperative morbidity and mortality ≤ 30 days, and pouch problems. Patients were also invited to participate in a case–control study in which the patients would respond to three different questionnaires, the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short Form-36 General Health Questionnaire (SF-36), and questions from the Pouch Dysfunction Score. We compared the responding TAMIS RPC patients to a Danish national cohort (0–10 years from RPC, n = 514) of patients having RPC between 1980 and 2010. We compared functional outcomes and QoL. Results: Four (4%) of the TAMIS patients had an anastomotic leak; none of these required re-operation with removal of the pouch. Anastomotic leak was treated with antibiotics and drain. Out of the four leaks, only one ended up with a permanent stoma; all others had their stoma reversed successfully. The TAMIS patients had the same number of bowel movements as the patients in the Danish national cohort study. The same was seen with regard to incontinence. We had no conversions in our series of TAMIS procedures. Conclusion: The TAMIS technique shows acceptable outcomes, both in regard to postoperative complications and also functional outcome and QoL.

Additional file 2. The written form that the surgeons registered immediately after surgery. TME, total mesorectal excision; PME, partial mesorectal excision.

Background Despite increasing focus on the technical performance of total mesorectal excision over recent decades, anastomotic leakage (AL) continues to be a serious complication for many patients, even in the hands of experienced surgical teams. This study describes implementation of standardized surgical technique in an effort to reduce variability, decrease the risk of anastomotic leakage, and improve associated short-term outcomes for rectal cancer patients undergoing robot-assisted restorative rectal resection (RRR). Methods We evaluated all rectal cancer patients undergoing robot-assisted RRR at Aarhus University Hospital between 2017 and 2020. Six standardized surgical steps directed to improve anastomotic healing were mandatory for all RRR. Additional changes were made during the period with prohibition of systemic dexamethasone and limiting the use of endoscopic stapling devices. Results The use of the full standardization, including all six surgical steps, increased from 40.3% (95% CI, 0.28–0.54) to 86.2% (95% CI, 0.68–0.95). The incidence of AL decreased from 21.0% (95% CI, 0.12–0.33) to 6.9% (95% CI, 0.01–0.23). Length of hospital stay (LOS) decreased from 6 days (range 2–50) to 5 days (range 2–26). The rate of patients readmitted within 90 days decreased from 21.0% (95% CI, 0.12–0.33), to 6.9% (95% CI, 0.01–0.23). Conclusion The full standardization was effectively implemented for rectal cancer patients undergoing robot-assisted RRR. The risk of AL, LOS and readmission decreased during the study period. A team focus on high-reliability and peri-operative complications can improve patient outcomes.

Additional file 1. A detailed description from Dr. Conor P. Delaney on how to perform a standardized restorative rectal resection.

Background and Aims: Increased small intestinal wall thickness correlates with both inflammatory activity and fibrosis in Crohn's disease [CD]. Assessment of perfusion holds promise as an objective marker distinguishing between the two conditions. Our primary aim was to determine if relative bowel wall perfusion measurements correlate with histopathological scores for inflammation or fibrosis in CD. Methods: A total of 25 patients were investigated before elective surgery for small intestinal CD. Unenhanced ultrasonography [US] and magnetic resonance enterography [MRE] were applied to describe bowel wall thickness. Perfusion was assessed with contrast-enhanced US [CEUS] and dynamic contrast-enhanced MRE [DCE-MRE]. Histopathology was used as gold standard. Results: Compared with histopathology, the mean wall thickness was 0.4 mm greater on US [range -0.3 to 1.0, p = 0.24] and 1.4 mm greater on MR [0.4 to 2.3, p = 0.006]. No correlation was found between the severity of inflammation or fibrosis on histopathology, and either DCE-MRE [r = -0.13, p = 0.54 for inflammation and r = 0.41, p = 0.05 for fibrosis] or CEUS [r = 0.16, p = 0.45 for inflammation and r = -0.28, p = 0.19 for fibrosis]. Wall thickness assessed with US was correlated with both histological inflammation [r = 0.611, p = 0.0012] and fibrosis [r = 0.399, p = 0.048]. The same was not true for MR [r = 0.41, p = 0.047 for inflammation and r = 0.29, p = 0.16 for fibrosis] Conclusions: Bowel wall thickness assessed with US is a valid marker of inflammation in small intestinal CD. However, relative contrast enhancement of US or of MRE cannot distinguish between inflammatory activity and fibrosis.

Background The ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain risk factors associated with failure. Method 1,991 patients with ulcerative colitis operated with ileal pouch-anal anastomosis in Denmark in the period 1980–2013 were included. Pouch failure was defined as excision of the pouch or presence of a stoma un-reversed within one year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary fecal diversion, annual hospital volume (very low=1-5 cases/year, low=6-10/year, intermediate=11-20/year, high>20/year), calendar year, laparoscopy, and primary sclerosing cholangitis. Results Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10-, and 20-year cumulative risks of 9.1%, 12.1%, and 18.2%, respectively. The risk of failure was higher for females (adjusted hazard ratio [aHR] 1.39, 95% CI: 1.10-1.75). Primary non-diversion (aHR 1.63, 95% CI: 1.11-2.41) and a low hospital volume (aHR, very low-volume vs. high-volume 2.30, 95% CI: 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy, or laparoscopy. Conclusion In a cohort of patients with ulcerative colitis and ileal pouch-anal anastomosis from Denmark, where pouch surgery is centralized, females had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure. This article is protected by copyright. All rights reserved.

BACKGROUND: The potential advantages of robot-assisted laparoscopy are being increasingly investigated, although data on its efficacy in benign colorectal surgery are scarce.OBJECTIVE: We compared the early postoperative outcome in robot-assisted IPAA with open surgery procedures.DESIGN: This was an observational study based on prospectively collected data obtained from chart reviews.SETTING: The single-center data set covers patients operated on from January 13, 2004, to September 16, 2014, at a specialist center.PATIENTS: Patients with ulcerative colitis undergoing IPAA surgery were included.MAIN OUTCOME MEASURES: Study end points included the duration of operation, admission length, complications (Clavien-Dindo), reoperations, and readmissions.RESULTS: Eighty-one robot-assisted and 170 open IPAA procedures were performed. The duration of operation was significantly longer for robot-assisted laparoscopic procedures (mean difference, 154 minutes; CI, 140-170). During a mean follow-up of 102 days, no significant differences in the distribution of complications were found (Spearman p = 0.12; p = 0.07), and no postoperative deaths occurred in either group. Postoperative admission length was shorter following robot-assisted procedures (mean difference, -1.9; CI, -3.5 to -0.3), whereas 40% of patients were readmitted, compared with 26% of patients who had open surgery (OR, 1.9; CI, 1.1-3.4). Pouch failure occurred in 3 patients (1 following robot-assisted laparoscopy; 2 following open surgery). On multivariate regression analyses, robot-assisted laparoscopy was associated with a significantly longer duration of operation (mean difference, 159 minutes; CI, 144-174), and more readmissions for any cause (OR, 2; CI, 1.1-3.7).LIMITATIONS: This was a nonrandomized, single-center observational study.CONCLUSION: In this implementation phase, robot-assisted IPAA surgery offers acceptable short-term outcomes. The limitations of this observational study call for randomized controlled trials with long-term follow-up and exploration of functional results.

Background: In this study, we investigated the effect of acute caffeine ingestion on physical performance after only 8 hours of caffeine abstinence. Methods: The study was a randomized, double-blind, cross-over study and included 30 healthy subject aged ≥70 years who had been recruited by their general practitioner. The participants abstained from caffeine for 8 hours (overnight) and the next morning they received placebo and then caffeine (6 mg/kg), or caffeine and then placebo at an interval of 1 week. One hour after the intervention we measured cycling endurance (ergometer), perceived effort during cycling (Borg scale), postural stability (force platform), and maximal isometric arm flexion strength and endurance (dynamometer chair). Blood samples were taken before the intervention, before cycling, after 5 minutes of cycling, and at exhaustion. Results: The participants had a usual coffee intake of six cups/day and after 8 hours of caffeine abstinence the plasma concentration of caffeine was 4.1 μM. Caf...

Aim Changes in postoperative fatigue, physical function and body composition were described in patients after open colorectal surgery, and factors that predicted postoperative fatigue 1 month after surgery were identified. Method Data from five clinical intervention studies from 1991 to 2005 were amalgamated. Patients (n = 385) were examined preoperatively, at discharge and 1 month postoperatively. The level of fatigue was scored subjectively from 1 ‘fit’ to 10 ‘fatigued’ on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, lean body mass and fat mass. A logistic regression analysis was used to identify the predictors of a high fatigue score 1 month postoperatively. Results Preoperatively, only 17% had a high fatigue score (≥ 5.5), whereas 65 and 30% had a high fatigue score at discharge and 1 month postoperatively, respectively. Postoperatively, there was a significant fall in physical performance, weight, lean body mass and fat mass that did not normalize by 1 month. High preoperative and discharge fatigue scores, major complications and the loss of lean body mass significantly increased the risk of fatigue 1 month postoperatively. Conclusion Open colorectal surgery was associated with a significant increase in postoperative fatigue and a decline in physical performance, weight and lean body mass. Major complications, a high perioperative fatigue score and the loss of lean body mass increased the risk of long-term fatigue.

Background Intermittent claudication is a disabling symptom of peripheral arterial disease for which few medical treatments are available. This study investigated the effect of caffeine on physical capacity in patients with intermittent claudication. Methods This randomized double-blind placebo-controlled crossover study included 88 patients recruited by surgeons from outpatient clinics. The participants abstained from caffeine for 48 h before each test and then received either a placebo or oral caffeine (6 mg/kg). After 75 min, pain-free and maximal walking distance on a treadmill, perceived pain, reaction times, postural stability, maximal isometric knee extension strength, submaximal knee extension endurance and cognitive function were measured. The analysis was by intention to treat. Results Caffeine increased the pain-free walking distance by 20·0 (95 per cent confidence interval 3·7 to 38·8) per cent (P = 0·014), maximal walking distance by 26·6 (12·1 to 43·0) per cent (P < 0·001), muscle strength by 9·8 (3·0 to 17·0) per cent (P = 0·005) and endurance by 21·4 (1·2 to 45·7) per cent (P = 0·004). However, postural stability was reduced significantly, by 22·1 (11·7 to 33·4) per cent with eyes open (P < 0·001) and by 21·8 (7·6 to 37·8) per cent with eyes closed (P = 0·002). Neither reaction time nor cognition was affected. Conclusion In patients with moderate intermittent claudication, caffeine increased walking distance, maximal strength and endurance, but affected balance adversely. Registration number: NCT00388128 (http://www.clinicaltrials.gov).

Summary Objective Whereas caffeine has been demonstrated to impact substantially on the metabolic response to exercise in healthy young subjects, this issue remains to be addressed in healthy elderly subjects. Design and participants The metabolic response to caffeine ingestion (6 mg/kg) and exercise in healthy elderly citizens at 70 years was examined in a randomized, double-blind, placebo-controlled, cross-over study. We included 30 subjects attending for driver license renewal at their general practitioner. Participants abstained from caffeinated drinks and food for 48 h and were randomized to receive placebo-caffeine or caffeine-placebo with 1 week between sessions. Measurements A cycling endurance test at 65% of the expected maximal heart rate was performed 1 h after intervention. Blood samples were taken before intervention, before cycling, after 5 min of cycling, and at exhaustion. Analysis was by intention-to-treat and P

The aim of the study was to describe changes in postoperative fatigue, quality of life, physical performance, and body composition in patients undergoing laparoscopic colonic cancer surgery.In a follow-up study from 2009-2011 at two regional hospitals in Denmark we examined 62 patients having a right hemicolectomy ora sigmoid resection performed. The main outcome measures were fatigue level subjectively scored from 1 ("fit") to 10 ("fatigued") on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, and lean body mass. Quality of life was assessed using the SF-36 questionnaire and pain using an ordinal scale. Patients were examined preoperatively, 1-2 and 4 weeks postoperatively.Eight patients (13%) were converted to open surgery and the median bleeding (95% confidence interval of the median) was 75 (50-100) ml. One to two weeks after surgery the fatigue level and pain when moving had increased significantly (p=0.0011 and p=0.0002 respectively) and the SF-36 physical component quality of life score decreased (p0.0001) when compared to preoperatively. However, at 4 weeks postoperatively fatigue level, pain, and quality of life scores were at the preoperative level. There were no significant changes from preoperatively to postoperatively in any of the measures of physical performance, whereas there was a slight reduction in weight and lean body mass after the operation. CONCLUSIONS. Laparoscopic colonic cancer surgery was associated with a short lasting increased fatigue and pain and reduced quality of life, but no significant reduction in physical performance after surgery.

UNLABELLED: The aim of the study was to describe changes in postoperative fatigue, quality of life, physical performance, and body composition in patients undergoing laparoscopic colonic cancer surgery.MATERIAL AND METHODS: In a follow-up study from 2009-2011 at two regional hospitals in Denmark we examined 62 patients having a right hemicolectomy ora sigmoid resection performed. The main outcome measures were fatigue level subjectively scored from 1 ("fit") to 10 ("fatigued") on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, and lean body mass. Quality of life was assessed using the SF-36 questionnaire and pain using an ordinal scale. Patients were examined preoperatively, 1-2 and 4 weeks postoperatively.RESULTS: Eight patients (13%) were converted to open surgery and the median bleeding (95% confidence interval of the median) was 75 (50-100) ml. One to two weeks after surgery the fatigue level and pain when moving had increased significantly (p=0.0011 and p=0.0002 respectively) and the SF-36 physical component quality of life score decreased (p

Revascularization of patients with intermittent claudication (IC) is recommended only for selected patients who have chronic pain or disabling disease. However, improvement in the quality of life (QoL) could justify more widespread use. Objectives: To determine the effect of conservative treatment and revascularization on the QoL and physical performance of selected patients with IC. Patients and Methods: This nonrandomized, parallel group, follow-up study included 83 patients with IC at Fontaine stage II. On the basis of interventional opportunities and the risks and benefits, combined with the preference of the patient, 47 patients were treated conservatively and 41 were revascularized. The patients were examined at inclusion and 3 months later. The evaluations included the QoL measure Short Form 36 (SF-36), the Walking Impairment Questionnaire (WIQ), pain-free and maximal walking distance (treadmill at 3 km/h, no incline), maximal isometric knee-extension strength and endurance, and ankle—brachial blood pressure index (ABI). Results: At baseline, the SF-36 and WIQ scores and the ABI were significantly lower in the patients selected for revascularization. After revascularization, all dimensions of QoL and functional status increased significantly in the patients who underwent revascularisation compared with the patients treated conservatively. The difference in the change in the physical component summary of SF-36 was 29.4% (P < .001), in the total WIQ 63.6% (P = .0002), and in the pain-free and maximal walking distances 313% (P < .001) and 135% (P < .001), respectively. After adjustment for age, smoking, ABI, body mass index (BMI), and baseline values, the differences remained statistically significant. Conclusion: Revascularization above the knee increased QoL, functional status, and walking distance significantly in patients with moderate IC.

Patients with intermittent claudication have a high risk of concomitant cardiovascular disease, and their risk factors should be identified and treated. The prognosis for the leg symptoms is relatively benign, as 75% of patients will stabilize or improve. Physical training, perhaps combined with pharmacotherapy, can usually increase walking distance substantially. The patient should be referred to a vascular surgeon for possible endovascular or surgical treatment if the symptoms significantly impair the patient's social life or working ability.

Patients with intermittent claudication have a high risk of concomitant cardiovascular disease, and their risk factors should be identified and treated. The prognosis for the leg symptoms is relatively benign, as 75% of patients will stabilize or improve. Physical training, perhaps combined with pharmacotherapy, can usually increase walking distance substantially. The patient should be referred to a vascular surgeon for possible endovascular or surgical treatment if the symptoms significantly impair the patient's social life or working ability. Udgivelsesdato: 2006-Jan-3

Summary Caffeine: physiological and pharmacologic aspects Ugeskr Læger 2004;166:2138-2142 Caffeine is the most widely used stimulant in the world. This is due not only to the fact that it is found in a great number of food products and is therefore readily available, but also because caffeine intake results in such positive effects as elation, pleasantness and better reactivity and because abstinence from caffeine can result in a withdrawal syndrome including headache, tiredness, restlessness and heart palpitations. Caffeine is also used in sports, as caffeine in moderate doses (3-6 mg/kg) can increase the endurance of athletes engaged in running, bicycling, swimming and other endurance sports. Caffeine is used both in training and in competitions, and the International Olympic Commitée (IOC) has included caffeine as a drug used for doping. There are several theories about caffeine's mechanism of action. The most likely and most recognized is the adenosine antagonist receptor theory, but it is also possible that caffeine exerts its effects through a different mechanism.

This study investigated the effect of caffeine on physical performance in healthy citizens agedor =70 yr. The randomized, double-blind, placebo-controlled, crossover study was conducted in 15 men and 15 women recruited by their general practitioner. Participants abstained from caffeine for 48 h and were randomized to receive one capsule of placebo and then caffeine (6 mg/kg) or caffeine and then placebo with 1 wk in between. One hour after intervention, we measured reaction and movement times, postural stability, walking speed, cycling at 65% of expected maximal heart rate, perceived effort during cycling, maximal isometric arm flexion strength, and endurance. Analysis was by intention to treat, and P0.05 was regarded as significant. Caffeine increased cycling endurance by 25% [95% confidence interval (CI): 13-38; P = 0.0001] and isometric arm flexion endurance by 54% (95% CI: 29-83; P = 0.0001). Caffeine also reduced the rating of perceived exertion after 5 min of cycling by 11% (95% CI: 5-17; P = 0.002) and postural stability with eyes open by 25% (95% CI: 2-53; P = 0.03). Caffeine ingestion did not affect muscle strength, walking speed, reaction, and movement times. At the end of the study, 46% of participants correctly identified when they received caffeine and placebo. Caffeine increased exercise endurance in healthy citizens agedor =70 yr, but the participants' reasons for stopping the test may have varied between subjects, as the cycling test was done at approximately 55% of maximal oxygen consumption. Further studies are required to investigate whether caffeine can be utilized to improve the physical performance of elderly citizens.

Udgivelsesdato: 2009-Oct OBJECTIVES: To evaluate the efficacy of pharmacological interventions in improving walking capacity and health-related quality of life for people with intermittent claudication. DATASOURCES: We searched Medline, EMBASE, Cochrane library and relevant websites for studies published from the start of the databases to February 2009. In addition, reference lists were manually searched. REVIEW METHODS: Based upon a power calculation, only robust (n>56), peer-reviewed, double-blinded, randomised and placebo-controlled trials were included. The main outcomes evaluated were maximal walking distance (MWD) and pain-free walking distance on a treadmill. Random models were used in the statistical analysis, and chi-square test were used to test for heterogeneity. RESULTS: Among 220 trials, only 43 trials fulfilled the quality criteria. Treatment periods, follow-up and treadmill protocols varied substantially. Vasodilator agents and phosphodiesterase inhibitors show robust significant results compared to placebo, but the improvements in MWD are modest. The highest benefit was caused by lipid-lowering agents, which in mean gained above 160 m in MWD, while the other agents only improved MWD about 50 m. CONCLUSION: Several drugs have shown to improve MWD, but with limited benefits. Statins seem to be the most efficient drug at the moment.