First experience of junior surgeons with laparoscopic totally extraperitoneal herniorrhaphy: Comparison with experienced surgeons in a single institution

Background/objectiveLaparoscopic totally extraperitoneal (TEP) herniorrhaphy is among the current leading inguinal hernia repair methods. This study aimed to investigate the safety and feasibility of a junior surgeon's first experience with laparoscopic TEP herniorrhaphy.MethodsA retrospective review was performed between January 2017 and December 2019 to analyze the medical records of patients with inguinal hernia who underwent laparoscopic TEP herniorrhaphy. The operative outcomes and complications of patients undergoing surgery by an experienced surgeon (group A, n = 100) were compared with those undergoing surgery by a junior surgeon (group B, n = 100).ResultsThe mean operative time for group B was significantly longer than that for group A (52.0 ± 15.1 min vs 60.1 ± 17.4 min; P = 0.03). A statistical difference was also found in the mean postoperative stay (1.1 ± 0.3 d vs 1.4 ± 0.7 d; P = 0.02) between the two groups. There were 2 and 3 cases of recurrence in these two groups respectively (P = 0.72). Considering the operating time as a variable of learning curve, significant stabilization can be achieved after 30 cases (67.3 ± 17.8 min vs 53.1 ± 11.1 min; P = 0.02).ConclusionsThe surgical outcomes of laparoscopic TEP herniorrhaphy performed by a well-trained junior surgeon were similar to the outcomes of an experience surgeon.     

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

IntroductionChildren with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the “modified 2-stage” approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.MethodsThis is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.ResultsN = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.ConclusionDelaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.     

Surgical Treatment of Mesenteric Lymphatic Malformations in Children: An Observational Cohort study

BackgroundFew studies have analyzed the cyst characteristics and complications of mesenteric lymphatic malformations (ML). This study aimed to compare ML's cyst characteristics and preoperative complications at different locations and suggest a modified ML classification for patients requiring surgery.MethodsIn total, 157 ML patients underwent surgery at Beijing Children's Hospital between January 2010 and December 2021. The cyst characteristics and preoperative complications were reviewed. The surgical methods for ML were analyzed according to the modified ML classification (Type I, n = 87, involving the intestinal wall; Type II, n = 45, located in the mesenteric boundaries; Type III, n = 16, involving the root of the mesentery; Type IV, n = 7, multicentric ML; Type V, n = 2, involving the upper rectum).ResultsOverall, 111 (70.7%) ML were located at the intestinal mesentery and 44 (28.0%) at the mesocolon. Type I and type II ML mainly involved intestinal mesentery (64.9%) and mesocolon (56.8%), respectively (P < 0.001). Microcystic-type ML and ML with chylous fluid were only located in the intestinal mesentery. Intestinal volvulus was only found in patients with ML in the intestinal mesentery (P < 0.001), whereas ML in the mesocolon were more prone to hemorrhage (P = 0.002) and infection (P = 0.005). ML in the jejunal mesentery was an independent risk factor for intestinal volvulus (OR = 3.5, 95% CI 1.5–8.3, P = 0.003). The surgical methods significantly differed between Type I and type II ML (P < 0.001).ConclusionsML at different locations have different characteristics. For patients requiring surgery, the new ML classification can be used to select an appropriate surgical method.Level of EvidenceLevel III.     

Completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy: Comparison of surgical complexity and prognosis

ObjectiveTo compare the operation complexity and prognosis of completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy.MethodsWe reviewed and analyzed the clinical data of 87 patients with infrahepatic tumor thrombus from January 2015 to April 2019 retrospectively. Completely laparoscopic infrahepatic tumor thrombectomy was completed in 41 cases, and open surgery was completed in 46 cases.ResultsAll 41 patients successfully completed laparoscopic operation, and there were no cases of death during the operation. The completely laparoscopic group were older, had smaller renal tumor diameter, shorter median operation time, lower median intraoperative hemorrhage volume, and lower median transfusion volume of suspended red blood cells compared with open surgeries. The proportion of low-level tumor thrombus (Mayo I) in the completely laparoscopic group was higher (63.4%), while the proportion of low-level tumor thrombus in the open surgery group was lower (30.4%) (P = 0.002). The postoperative complications incidence of laparoscopic surgery was 19.5%, which was lower than that of open surgery (47.8%) (P = 0.004). The mean cancer-specific survival time of the laparoscopic surgery group was 36.6 ± 2.5 months, while that of the open surgery group was 32.3 ± 2.7 months (P = 0.277). There was no statistical difference between the two groups.ConclusionAlthough completely laparoscopic radical nephrectomy and infrahepatic tumor thrombectomy is a challenging operation, it could be feasible and safely performed, especially in the hands of highly-experienced laparoscopic urologists for well selected cases.     

Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi‐port laparoscopy

Aim

Single port (SP) ileocaecal resection (ICR) is an established technique but there are no large studies comparing SP and multi‐port (MP) laparoscopic surgery in Crohn's disease (CD). The aim of this study was to compare postoperative pain scores and analgesia requirements after SP and MP laparoscopic ICR for CD.

Method

This was a retrospective study of patients undergoing SP or MP ICR for CD in three tertiary referral centres from February 1999 to October 2014. Baseline characteristics (age, sex, body mass index and indication for surgery) were compared. Primary end‐points were postoperative pain scores, analgesia requirements and short‐term postoperative outcomes.

Results

SP ICR (n = 101) and MP ICR (n = 156) patients were included in the study. Visual analogue scale scores were significantly lower after SP ICR on postoperative day 1 (P = 0.016) and day 2 (P = 0.04). Analgesia requirements were significantly reduced on postoperative day 2 in the SP group compared with the MP group (P = 0.007). Duration of surgery, conversion to open surgery and stoma rates were comparable between the two groups. Surgery was more complex in terms of additional procedures when MP was adopted (P = 0.001). There were no differences in postoperative complication rates, postoperative food intake, length of stay and readmissions.

Conclusion

These data suggest that in comparison to standard laparoscopic surgery SP ICR might be less painful and patients might require less opioid analgesia.     

Palliative stoma creation: comparison of laparoscopic vs conventional procedures

Background  The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis. Materials and methods  In two prospective country-wide multicentre studies, each conducted over a similar period of time, the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared. Results  A total of 90 patients underwent palliative laparoscopic construction; 550 patients received a stoma via a laparotomy. The intra-operative complication rate was lower after open surgery than after laparoscopic surgery (2.7 vs 5.6%; p = 0.15), although the difference was not significant. With regard to general (30.9 vs 15.6%; p = 0.003) and also specific postoperative complications (13.8 vs 5.6%; p = 0.029), however, a significant advantage of the laparoscopic approach was seen. Furthermore, mortality in the laparoscopic group was also significantly lower (4.4 vs 14.0%; p = 0.011). Conclusion  Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure.     

Major stoma related morbidity in young children following stoma formation and closure: A retrospective cohort study

BackgroundLittle is known about stoma related morbidity in young children. Therefore, the aim of this study is to assess major morbidity after stoma formation and stoma closure and its associated risk factors.MethodsAll consecutive young children (age ≤ three years) who received a stoma between 1998 and 2018 at our tertiary referral center were retrospectively included. The incidence of major stoma related morbidity (Clavien-Dindo grade ≥III) was the primary outcome. This was separately analysed for stoma formation alone, stoma closure alone and all stoma interventions combined. Non-stoma related morbidity was excluded. Risk factors for major morbidity were identified using multivariable logistic regression analysis.ResultsIn total 336 young children were included with a median follow-up of 6 (IQR:2–11) years. Of these young children, 5% (n = 17/336) received a jejunostomy, 57% (n = 192/336) an ileostomy, and 38% (n = 127/336) a colostomy. Following stoma formation, 27% (n = 92/336) of the young children experienced major stoma related morbidity, mainly consisting of high output stoma, prolapse and stoma stenosis. The major morbidity rate was 23% (n = 66/292) following stoma closure, most commonly comprising anastomotic leakage/stenosis, incisional hernia and adhesive obstructions. For combined stoma interventions, major stoma related morbidity was 39% (n = 130/336). Ileostomy was independently associated with a higher risk of developing major morbidity following stoma formation (OR:2.5; 95%-CI:1.3–4.7) as well as following closure (OR:2.7; 95%-CI:1.3–5.8).ConclusionsMajor stoma related morbidity is a frequent and severe clinical problem in young children, both after stoma formation and closure. The risk of morbidity should be considered when deliberating a stoma.     

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BackgroundAortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort.MethodData were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group.Results63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955).ConclusionReduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.     

Comparison of robotic reduced-port and laparoscopic approaches for left-sided colorectal cancer surgery

Background/objectiveThe reduced-port approach can overcome the limitations of single-incision laparoscopic surgery while maintaining its advantages. Here, we compared the effects of robotic reduced-port surgery and conventional laparoscopic approaches for left-sided colorectal cancer.MethodsBetween January 2015 and December 2016, the clinicopathological characteristics and treatment outcomes of 17 patients undergoing robotic reduced-port surgery and 49 patients undergoing laparoscopic surgery for left-sided colorectal cancer were compared.ResultsThe two groups were comparable in almost all outcome measures except for the distal resection margin, which was significantly longer in the laparoscopic group (P < 0.001). The between-group differences in reoperation, incisional hernia development, and overall and progression-free survival were nonsignificant; however, the total hospital cost was significantly higher in the robotic group than in the laparoscopic group (US$13779.6 ± US$3114.8 vs. US$8556.3 ± US$2056.7, P < 0.001).ConclusionRobotic reduced-port surgery for left-sided colorectal cancer is safe and effective but more expensive with no additional benefit compared with the conventional laparoscopic approach. This observation warrants further evaluation.     

A defunctioning stoma significantly prolongs the length of stay in laparoscopic colorectal resection

Background  Reduction in length of stay has several advantages, including healthcare costs, patient choice, and minimizing hospital acquired infections. Additionally, length of stay is a surrogate marker of rate of recovery from the physiological insult of anaesthesia and surgery and complications thereof. A well-documented short-term benefit of laparoscopic compared to open colorectal resection is reduced length of stay. Methods  This was a review of prospectively collected data on all laparoscopic colorectal resections performed in our unit. We analyzed patients having primary colorectal anastomosis, to assess the effect of conversion compared to completion laparoscopically. Furthermore we compared those with or without diverting stoma, for the effect of stoma formation on postoperative length of stay (LOS). Results  Two hundred and thirteen patients had a colorectal resection. Of these 133 (62%) were left-sided or rectal resections. Resection with primary colorectal anastomosis was undertaken in 112 patients. A defunctioning stoma was performed in 13/112 (12%), and 32/112 (29%) were converted as the procedure could not be completed laparoscopically. Conversion was not significantly associated with increased LOS with weighted median of 6.5 and 6 days for conversion and no conversion, respectively. However, stoma formation significantly increased LOS to a median of 10 days compared with a median of 6 days in patients without a stoma (p = 0.001, Mann–Whitney U). Conclusions  The need for conversion, if performed in a timely and appropriate manner, has little impact on patient outcome compared to those completed laparoscopically, with no significant increase in LOS in our experience. In contrast, a diverting stoma does prolong LOS and some of the benefits of laparoscopic surgery may be lost unless patients requiring a stoma are identified preoperatively and have intensive pre- and postoperative stoma training.     

Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: Which patients receive a stoma and how often are they reversed?

BackgroundThe surgical management of large bowel obstruction (LBO) is heterogeneous and influenced by multiple variables. The aim of this study was to analyze and compare the surgical interventions and outcomes of patients necessitating surgery for LBO.MethodsPatients with LBO between 2000 and 2017 were included. Main outcomes measures are intraoperative findings, operative management, post-operative outcomes and stoma closure rates.Results133 patients were included with predominately left-sided obstruction (82%). The most common etiology was colorectal cancer (44%) followed by extrinsic malignant compression (29%). The most common operation performed was fecal diversion without resection (46%). This group had significantly more stage 4 carcinoma, carcinomatosis and had the lowest stoma closure rate (16%).Eighty-six percent of the operated patients underwent fecal diversion, of these, 27% had stoma reversal at 6 months. Patients that had a resection and anastomosis with diverting loop ileostomy were most likely to undergo stoma reversal (p = 0.005) and had the lowest number of patients with stage-IV carcinoma.ConclusionsIn this single institution analysis, the management of LBO entails high operative and stoma rates, with less than 30% of patient undergoing stoma closure. Resection, anastomosis and DLI had the highest chance of stoma reversal.     

Single-port laparoscopic appendicectomy versus conventional three-port approach for acute appendicitis: A systematic review,meta-analysis and trial sequential analysis of randomised controlled trials

AimsThe aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis.MethodsA comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters.ResultsSixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD −0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD −2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection.ConclusionAlthough SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.     

High incidence of late anastomosis leakage in patients for rectal cancer after neoadjuvant chemoradiotherapy: A comparative study

PurposeThe purpose of this study was to investigate the clinical features and risk factors of late anastomotic leakage (AL) in a homogeneous cohort with elective sphincter-sparing surgery (SSS) with ileostomy after neoadjuvant chemoradiotherapy (nCRT) for rectal cancer.MethodsData from a total of 359 patients who underwent elective rectal cancer surgery between Jan 2017 and May 2020 were retrospectively reviewed. Patients were classified into early and late AL groups, referring to onset of AL occurring within or after 30 post-operative days, respectively. We analyzed clinical, pathological, and inflammatory features of both AL and risk factors of stoma reversal failure and late AL.ResultsA total of 85 patients with SSS with ileostomy after nCRT were classified into 8 (9.4%) patients of early AL and 16 (18.8%) of late AL. Unlike early AL patients, late AL group showed lower neutrophil-lymphocyte ratio (NLR) (P < 0.001) and did not need an invasive intervention at the time of diagnosis. 50% (5/10) patients needed reformation of ileostomy. (P = 0.048) Failure of stoma reversal is associated with advanced stages, high NLR ratio (≥3), and inflammatory lesions seen around anastomosis in radiologic findings, which was confirmed as the risk factor of late AL.ConclusionLate AL, with different clinical features, showed a higher incidence than early AL in patients who underwent surgery after nCRT and also had a higher stoma reformation rate. Careful evaluation using laboratory and radiological findings before an ileostomy closure is performed to prevent late AL.     

Adult primary prostate sarcoma: A multi-center cohort study and comparison between Chinese and American cases

Background/objectivesTo assess the effects of clinical factors and treatments on the overall survival (OS) of patients with prostate sarcomas.MethodsWe reported 41 cases diagnosed with prostate sarcomas from eight hospitals in China and retrospectively analyzed the prognostic factors by combining our data with cases from five previously published cohorts, including one extra Chinese cohort and four cohorts from US cohorts. Additionally, we investigated the differences in treatment regimens between China (n = 66) and the USA (n = 74).ResultsThe median survival time of the 41 cases was 18.6 months (95% confidence interval [CI]: 13.9–23.2). The status of negative distant metastasis (P = 0.004) and radical tumor resection with negative margin (P = 0.001) were significantly associated with better overall survival, whereas age, tumor size, duration of initial symptoms, and chemo/radiotherapy were not significantly related to OS. The survival time was longer in patients with rhabdomyosarcoma than in those with leiomyosarcoma (P = 0.049). Combined analysis of the current and 5 prior cohorts showed that more patients in the US cohorts underwent radical surgery (P = 0.005), and the overall survival was better among those with radical cystoprostatectomy compared to those with radical prostatectomy alone (P = 0.008).ConclusionRadical resection to achieve a negative margin contributes to better survival for patients with prostate sarcoma.     

Proximal aortic repair in dialysis patients: A national database analysis

ObjectivesDialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.MethodsPerioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.ResultsIn patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.ConclusionsWe described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.     

Results of a colorectal enhanced recovery after surgery (ERAS) programme and a qualitative analysis of healthcare workers’ perspectives

BackgroundEnhanced recovery after surgery (ERAS) is a structured programme using a multimodal, evidence-based approach to improve post-operative outcomes. Successful implementation of ERAS can be challenging. We aimed to evaluate our initial experience with colorectal ERAS and explore the perspectives of specialist doctors and nurses.MethodsFrom 1 June 2017 to 31 December 2017, all patients who underwent elective colorectal resection and met the ERAS inclusion criteria at the Department of Colorectal Surgery, Singapore General Hospital, were included in the study. Short-term outcomes were compared between patients with >70% compliance to key ERAS components versus those with ≤70% compliance. Department staff were surveyed via questionnaire in July 2019.ResultsThree hundred and fifteen patients were included in study. >70% ERAS compliance rate was achieved in 84 patients (26.7%). A higher compliance rate resulted in a significantly shorter length of stay of 6 (IQR 5–8) days vs. 7 (IQR 6–9.5) days (p = 0.025) and lower readmission rate of 3.6% (n = 3) vs. 4.8% (n = 11) (p = 0.042), as well as a trend towards reduced complication rate of 15.4% (n = 13) vs. 22.0% (n = 51) and earlier return to gastrointestinal function. There was a 100% questionnaire response amongst all 12 colorectal surgeons and 5 colorectal resident nurse practitioners.ConclusionIncreased adherence to the components of ERAS results in better early outcomes and may have long-term benefits on survival. Effective communication and professional support for the ERAS multi-disciplinary team, as well as understanding healthcare workers’ concerns and addressing long-standing practices, is essential for successful implementation of the programme.     

Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers

BackgroundTo evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers.MethodsFifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed.ResultsThe mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person.ConclusionsLaparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.     

Comparing shared decision making using a paper and digital consent process. A multi-site,single centre study in a trauma and orthopaedic department

IntroductionThe importance of shared decision making (SDM) for informed consent has been emphasised in the updated regulatory guidelines. Errors of completion, legibility and omission have been associated with paper-based consent forms. We introduced a digital consent process and compared it against a paper-based process for quality and patient reported involvement in shared decision making.Methods223 patients were included in this multi-site, single centre study. Patient consent documentation was by either a paper consent form or the Concentric digital consent platform. Consent forms were assessed for errors of legibility, completion and accuracy of content. Core risks for 20 orthopaedic operations were pre-defined by a Delphi round of experts and forms analysed for omission of these risks. SDM was determined via the ‘collaboRATE Top Score’, a validated measure for gold-standard SDM.Results72% (n = 78/109) of paper consent forms contained ≥1 error compared to 0% (n = 0/114) of digital forms (P < 0.0001). Core risks were unintentionally omitted in 63% (n = 68/109) of paper-forms compared to less than 2% (n = 2/114) of digital consent forms (P < 0.0001). 72% (n = 82/114) of patients giving consent digitally reported gold-standard SDM compared to 28% (n = 31/109) with paper consent (P < 0.001).ConclusionImplementation of a digital consent process has been shown to reduce both error rate and the omission of core risks on consent forms whilst increasing the quality of SDM. This novel finding suggests that using digital consent can improve both the quality of informed consent and the patient experience of SDM.     

What are the results of laparoscopic re-operative rectal surgery?

IntroductionReoperative rectal surgery is challenging, performed selectively by experienced colorectal surgeons. The minimally invasive approach has not been well defined. This study reviewed the results of laparoscopy in this challenging setting.MethodsRetrospective analysis of patients who underwent trans-abdominal re-operative rectal surgery from 2010 to 2019 was performed.ResultsSeventy-eight patients [35 females (45%); BMI 25kg/m2) were included. Reasons for reoperation were recurrent cancer in 18 (43%) patients and anastomotic failure in 57 (73%). Twenty-two (28%) had laparoscopic surgery and 4 had attempted laparoscopy converted to laparotomy. A higher success rate was noted for laparoscopy with prior laparoscopic surgery. Benefits of laparoscopy included significant reduction in length of stay (6.7 vs 9.7 days, p = 0.012) and abdominal superficial surgical site infection (0% vs 25%, p < 0.001) and higher rate of achieving bowel continuity compared to laparotomy (77% vs 50%, p = 0.021)ConclusionsReoperative laparoscopic rectal surgery is safe and feasible in the context of a high-volume laparoscopic surgeon with substantial experience in redo proctectomies. It offers clear benefits including decreased surgical site infection rates and length of stay.     

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial

IntroductionBreast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure.MethodsA randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the “reshaping” group (closure of excision defect with mobilised breast tissue; n = 124) and to the “control” group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ).ResultsThere were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of “good” or “excellent” by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001).ConclusionsSimple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.