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Gut 2004;53:387-391. doi: 10.1136/gut.2003.020503 Objective: To determine the effectiveness and efficiency of the Department of Health's new general practitioner referral guidelines for bowel cancer. Design: One year prospective audit. Setting: [...]

Aim: Pilonidal disease is a benign condition that affects mainly the young. In existing literature, there is no consensus for best treatment, with multiple operative techniques described, some complex, resulting in a high proportion of failure and/or morbidity. The cleft closure (or cleft lift) described by Bascom and Bascom (Arch Surg, 137, 2002, 1146-50), by comparison, is a simple operation, resulting in healing in the majority and good cosmesis., Method: This is a single surgeon series, with the aim of evaluating outcomes for consecutive patients who underwent cleft closure surgery at two centres (St Mark's Hospital, London, and Queen Alexandra Hospital, Portsmouth) between 1995 and 2021 for either extensive, complex or recurrent pilonidal disease. Primary study outcomes that were measured included rate of primary healing, time to complete healing and rate of recurrence., Results: Some 714 patients had a cleft closure of whom 656 had documented follow-up. Primary healing occurred in 60.7% (n = 398) rising to 88.5% by 12 weeks (n = 562) and 91.8% by 16 weeks. The remaining patients healed over the following weeks with only 19 wounds failing to heal completely (3%), requiring further surgery to achieve healing. After complete healing 5.3% of patients developed recurrent disease at a median of 12 months., Conclusion: Cleft closure is an effective operation for pilonidal disease. Overall, 97% of patients healed without further surgery. A 3% failure rate and 5.3% recurrence rate were observed. This technique could be considered as an alternative procedure to complex flaps or midline excision, in extensive, recurrent and unhealed pilonidal disease., (© 2023 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Data analytics and artificial intelligence (AI) have been used to predict patient outcomes after colorectal cancer surgery. A prospectively maintained colorectal cancer database was used, covering 4336 patients who underwent colorectal cancer surgery between 2003 and 2019. The 47 patient parameters included demographics, peri- and post-operative outcomes, surgical approaches, complications, and mortality. Data analytics were used to compare the importance of each variable and AI prediction models were built for length of stay (LOS), readmission, and mortality. Accuracies of at least 80% have been achieved. The significant predictors of LOS were age, ASA grade, operative time, presence or absence of a stoma, robotic or laparoscopic approach to surgery, and complications. The model with support vector regression (SVR) algorithms predicted the LOS with an accuracy of 83% and mean absolute error (MAE) of 9.69 days. The significant predictors of readmission were age, laparoscopic procedure, stoma performed, preoperative nodal (N) stage, operation time, operation mode, previous surgery type, LOS, and the specific procedure. A BI-LSTM model predicted readmission with 87.5% accuracy, 84% sensitivity, and 90% specificity. The significant predictors of mortality were age, ASA grade, BMI, the formation of a stoma, preoperative TNM staging, neoadjuvant chemotherapy, curative resection, and LOS. Classification predictive modelling predicted three different colorectal cancer mortality measures (overall mortality, and 31- and 91-days mortality) with 80-96% accuracy, 84-93% sensitivity, and 75-100% specificity. A model using all variables performed only slightly better than one that used just the most significant ones., (© 2022. The Author(s).)

Background: Complete mesocolic excision (CME) for right colon cancers has traditionally been an open procedure. Surgical adoption of minimal access CME remains limited due to the technical challenges, training gaps and lack of level-1 data for proven benefits. Currently there is limited published data regarding the clinical results with the use of robotic CME surgery. Aim To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME., Aim: To report our experience, results and techniques, highlighting a clinical and oncological results and midterm oncological outcomes for robotic CME., Methods: All patients undergoing standardised robotic CME technique with SMV first approach between January 2015 and September 2019 were included in this retrospective review of a prospectively collected database. Patient demographics, operative data and clinical and oncological outcomes were recorded., Results: Seventy-seven robotic CME resections for right colonic cancers were performed over a 4-year period. Median operative time was 180 (128-454) min and perioperative blood loss was 10 (10-50) ml. There were 25 patients who had previous abdominal surgery. Median postoperative hospital stay was 5 (3-18) days. There was no conversion to open surgery in this series. Median lymph node count was 30 (10-60). Three (4%) patients had R1 resection. There was one (1%) local recurrence in stage III disease and 4(5%) distal recurrence in stage II and stage III. There was no 30- or 90-day mortality. Three-year disease-free survival was 100%, 91.7% and 92% for stages I, II and III, respectively. Overall survival was 94%., Conclusions: Robotic CME is feasible, effective and safe. Good oncological results and improved survival are seen in this cohort of patients with a standardised approach to robotic CME., (© 2021. The Author(s).)

Background  Minimal access surgery is associated with improved cosmetic and other short-term outcomes. Conventionally, an abdominal incision is made for specimen extraction. We assessed the feasibility of specimen extraction through one of the natural orifices and analyzed its impact on short-term outcomes. Methods  A prospectively collected data were reviewed on consecutive patients who underwent natural orifice specimen extraction (NOSE) after laparoscopic colorectal surgery. The results were compared with a matched group who had transabdominal extraction (TAE) of the specimens. A systematic literature review was performed to compare our results. Results  The combined median operating time for right and left colectomies was significantly higher in the NOSE group as compared with TAE group (260 vs. 150). There was no mortality in either group and no conversions to TAE in the NOSE group. No local metastasis or major iatrogenic injuries were reported at the time of retrieval. The results were comparable to those of a meta-analysis of randomized controlled trials. Conclusion  The results of NOSE are comparable to those of TAEs. The absence of a minilaparotomy for specimen extraction may lead to a speedy recovery and better cosmesis., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Background: The surgical treatment options for low rectal cancer patients include the Abdominoperineal Resection and the sphincter saving Low Anterior Resection. There is growing evidence towards better outcomes for patients being treated with a Low Anterior Resection compared to an Abdominoperineal Resection., Objective: The aim of this study was to evaluate the short term and oncological outcomes in low rectal cancer treatment., Design: This is a retrospective cohort study of prospectively collected data., Setting: Rectal cancer patients from a single center in the United Kingdom., Patients: Patients included all low rectal cancer patients (≤ 6 cm from the anal verge) undergoing Low Anterior Resection or Abdominoperineal Resection between 2006 and 2016., Outcome Measures: To identify differences in postoperative complications and disease free and overall survival., Results: A total of 262 patients were included for analysis (Low Anterior Resection n = 170, Abdominoperineal Resection n = 92). Abdominoperineal Resection patients were significantly older (69 versus 66 years), had lower tumours (3 versus 5 cm), received more neo-adjuvant radiation, had longer hospital stay and more complications (wound infections and wound dehiscence). Low Anterior Resections had a significantly higher number of harvested lymph nodes (17 versus 12) however there was no difference in nodal involvement and R0 resection rate. No significant difference was found for recurrence, overall survival and disease free survival., Limitation: Retrospective review of cancer database and single center data., Conclusion: In the treatment of low rectal cancer Abdominoperineal Resection is associated with higher rates of postoperative complications and longer hospital stay compared to the Low Anterior Resection, with similar oncological outcomes., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2021.)

Minimally invasive surgery for total mesorectal excision (TME) remains technically challenging due to poor maneuverability within the pelvis, which makes extremely difficult to introduce a laparoscopic stapler (LS) for the rectal transection. We aim to perform a systematic review and meta-analysis on robotic TME after the use of robotic stapler (RS) or LS after robotic TME. A systematic literature search was performed using PubMed, MEDLINE, and Cochrane Database. Participants who underwent robotic anterior resection were considered following these criteria: (1) studies comparing RS and LS; (2) studies reporting the rate of anastomotic leakage (AL). The primary outcome was the risk of AL. Secondary outcomes included the number of firings of stapler needed. A meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement was performed. A total of 4 studies including 391 patients (LS = 251, RS = 140) were included for analysis. Regarding the number of firings, overall results suggest that the rectal stapling was achieved with less firings in the RS group, but the difference is not significant [risk difference, (95% CI) 0.42 (- 0.13, 0.97)]. There was a 56% increased odds of AL for LS compared with RS; however, this was not statistically significant (OR: 1.56; 95% CI 0.59, 4.14). With the current literature evidence, the present study could not demonstrate a clear benefit of the RS over the LS. Although the development of an AL is multifactorial and unpredictable, our data may suggest that the use of the RS could help reducing the risk of AL. There is a need of future randomized clinical trial to assess the possible benefits of the RS.