Robotic total mesorectal excision for rectal cancer

Robotic TME is an evolution of the classic laparoscopic technique with an aim to overcome the limitations of the non-articulating laparoscopic instruments within the narrow confines of the pelvis. The purpose of this chapter is to share our experience and the experience of others in this constantly evolving field of robotic TME. In the context of pelvic dissection, there are several properties that make the robotic system more advantageous to use as compared to laparoscopic or open techniques. The platform provides very stable optics with the surgeon in control of the camera, allowing for constant adjustments. This, together with simultaneous control of three working, articulating wrist instruments, gives the surgeon the ability to completely control the operating field. This is often essential when working with obese patients, bulky tumors, or within the narrow pelvic confines. Despite many factors that allow for easier completion of this task, it still remains an advanced procedure and is associated with a steep learning curve. Many studies have documented use of the robotic total mesorectal excision technique to be associated with decreased conversion rates, improved mesorectal envelope completeness, and improved genitourinary function. Still, there have been no randomized controlled trials proving unequivocally the superiority of this technique over the other approaches. At the present time, robotic technology should not be treated as a replacement for other techniques, but rather as an available, and powerful tool in a surgeon’s armamentarium. Because of the very high cost of this technology, the most practical option is to select the population of patients that may be best served through use of these surgical techniques

Robotowa operacja naprawcza wypadania odbytnicy ze współistniejącymi rectocele i sigmoidocele z użyciem siatki

Wypadanie odbytnicy (WO) jest schorzeniem występującym najczęściej u pacjentów w wieku powyżej 50 lat, szczególnie u kobiet. Z WO zazwyczaj współistnieją inne patologie, takie jak: uwypuklenie odbytnicy (rectocele), wpuklenie esicy (sigmoidocele), uwpuklenie pęcherza moczowego (cystocele), a nawet przepuklina zawierająca pętle jelita cienkiego (enterocele). Rektopeksja z użyciem siatki jest metodą o powszechnie uznawanej skuteczności w leczeniu wypadania odbytnicy. Zastosowanie robota chirurgicznego ułatwia preparowanie tkanek w obrębie miednicy mniejszej i jest szczególnie pomocne podczas zakładania szwów mocujących siatkę. W niniejszym artykule przedstawiono przypadek 77-letniej kobiety, u której stwierdzono objawy zespołu zaburzeń defekacji (ang. obstructed defecation syndrome; ODS), którego przyczyną było wypadanie odbytnicy. W trakcie postępowania przedoperacyjnego objawy pacjentki w skali ODS Score oceniono na 9/20. Podczas dalszej diagnostyki, poza wypadaniem odbytnicy, stwierdzono współistniejące rectocele i sigmoidocele. Pacjentka została zakwalifikowana do robotowej rektopeksji z użyciem siatki. W pierwszym etapie operacji wykonano uwolnienie tylnej części mezorektum z zaoszczędzeniem nerwów układu autonomicznego. Następnie wypreparowano przegrodę odbytniczo-pochwową, oddzielając pochwę od przedniej części odbytnicy do poziomu mięśni dźwigaczy odbytu (mięśni dna miednicy) i rozworu moczowo-płciowego, co umożliwiło przymocowanie siatki polipropylenowej do przedniej ściany odbytnicy. Podwieszenie przedniej ściany odbytnicy przy użyciu siatki rozwiązało problem trzech współistniejących patologii. U pacjentki w trakcie dwuletniej obserwacji nie odnotowano nawrotu ani istotnych powikłań pooperacyjnych, a wynik ODS Score uległ obniżeniu do 1/20

Robotic Combined Anterior & Posterior Repair of a Rectal Prolapse, Rectocele, and Sigmoidocele with a Mesh

RP is often seen in patients over the age of fifty, particularly women. These patients frequently suffer from other concomitant pathologies like rectocele, sigmoidocele, cystocele, or even enterocele. Rectopexy with a mesh has been an established treatment for rectal prolapse. The utilization of the robotic system allows for a successful repair within a confined pelvic space, especially for precise suture placement when working with the mesh. A 77-year-old female presented with ODS symptoms found to be caused by a progressive rectal prolapse. Her pre-operative ODS score was 9/20. Pelvic floor evaluation revealed concomitant rectocele and sigmoidocele. The patient was offered a robotic-assisted rectopexy with mesh placement to address the three concomitant pathologies. During the procedure, a posterior mesorectal mobilization with autonomic nerve preservation was performed to address the posterior leading edge of the prolapse. Subsequently, the vagina was separated from the anterior portion of the rectum and dissected down to the levator ani muscle and the perineal body. This allowed for the affixation of a polypropylene mesh to the anterior portion of the rectum. Anterior suspension of the mobilized rectum with the mesh addressed all three pathologies. No recurrence or complications occurred at two-year follow-up. The patient’s ODS score decreased to 1/20

Disparities in screening for colorectal cancer based on limited language proficiency

Background:This study analyzes the association between limited language proficiency and screening for colorectal cancer. Methods:This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups. Results:Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P \u3c .001), less physician recommendation for a colonoscopy (87 vs 60%, P \u3c .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P \u3c .001), and fewer fecal occult blood samples overall (P \u3c .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P \u3c .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with Spanish language and other language variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates. Discussion:Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup

Protocol-based intravenous fluid hydration for newly created ileostomies decreases readmissions secondary to dehydration

Background: Newly created ileostomies often result in patient readmission due to dehydration secondary to high ostomy output. Implementation of a mandatory home intravenous hydration protocol can avoid this. We aim to evaluate the impact of mandatory home intravenous hydration for patients with newly created ileostomies. Materials and methods: All patients at a single, tertiary care center who underwent ileostomy creation during a period of sporadic home intravenous hydration (February 2011-December 2013) and mandatory protocol hydration (March 2016-December 2018) were reviewed for incidence of dehydration, readmissions, and emergency department visits. Results: 241 patients were evaluated. 119 were in the sporadic group and 122 were in the protocol group. Operative approach differed among both groups, with hydration protocol patients undergoing 15% less open procedures and 4.9% more hand-assisted laparoscopic procedures (P = .0017). Prior to protocol implementation, 23.5% of patients were sent home with intravenous hydration. Length of hospital stay after index ileostomy creation was shorter for protocol patients by 3.3 days (P \u3c .0001). 15.1% of sporadic patients experienced dehydration as compared to 7.4% of protocol patients (P = .0283). Following protocol implementation, the number of patients readmitted due to dehydration increased from 13 to 14 (P = .01). Discussion: Standardized, mandatory at-home intravenous hydration following ileostomy creation leads to a significant reduction in postoperative incidence of dehydration and dehydration-associated readmissions. This protocol should be followed for all patients with newly created ileostomies, so long as adequate home health nursing support and active surveillance are available

Use of botulinum toxin injections for the treatment of chronic anal fissure: Results from an American Society of Colon and Rectal Surgeons survey

Background: Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. Methods: A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. Results: 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. Discussion: Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care

Correlation of tumor response between flexible sigmoidoscopy and magnetic resonance imaging in patients undergoing neoadjuvant therapy for locally advanced rectal cancer: A retrospective review

Background:The National Accreditation Program for Rectal Cancer recommends a pelvic MRI to assess the response to neoadjuvant therapy for advanced rectal cancers. However, there is no single restaging modality that can identify all patients with complete tumor response. At our institution, we perform both a pelvic MRI and a flexible sigmoidoscopy (FS) after neoadjuvant therapy prior to surgical resection. Objective: The objective is to elucidate the correlation of tumor response between FS and MRI in patients undergoing neoadjuvant therapy for locally advanced rectal cancer. Design: Single institution from 2010 to 2019. Retrospective cohort study comparing local tumor response on FS to MRI utilizing final pathology as the gold standard for comparison. Patients: Patients with confirmed locally advanced rectal adenocarcinoma (stage II or III) who underwent neoadjuvant therapy prior to surgical intervention and underwent flexible endoscopy and a standardized rectal cancer protocol MRI to evaluate tumor response. Results: A total of 48 patients were evaluated. Seven (14%) patients had a complete pathological response. MRI adequately reported 1 (14%), while FS found 4 (57.14%) out of the 7 complete responders. Nevertheless, this did not reach statistical significance ( P = .06). On logistic regression analysis, flexible sigmoidoscopy had a 5.5 higher likelihood to report an accurate complete response (OR 5.5, 95% CI: 1.02-29.64; P = .047). Conclusions: Flexible sigmoidoscopy should be used in conjunction with MRI in the work up of patients who have received neoadjuvant therapy for advanced rectal cancer prior to surgical resection