The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI

Objective  The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland.
Method  A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide .
Results  Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48–60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding.
Conclusion  Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.     

Simultaneous Resections of Colorectal Cancer and Synchronous Liver Metastases: A Multi-institutional Analysis

Background The safety of simultaneous resections of colorectal cancer and synchronous liver metastases (SCRLM) is not established. This multi-institutional retrospective study compared postoperative outcomes after simultaneous and staged colorectal and hepatic resections. Methods Clinicopathologic data, treatments, and postoperative outcomes from patients who underwent simultaneous or staged colorectal and hepatic resections at three hepatobiliary centers from 1985–2006 were reviewed. Results 610 patients underwent simultaneous (n = 135) or staged (n = 475) resections of colorectal cancer and SCRLM. Seventy staged patients underwent colorectal and hepatic resections at the same institution. Simultaneous patients had fewer (median 1 versus 2) and smaller (median 2.5 versus 3.5 cm) metastases and less often underwent major (≥ three segments) hepatectomy (26.7% versus 61.3%, p < 0.05). Combined hospital stay was lower after simultaneous resections (median 8.5 versus 14 days, p < 0.0001). Mortality (1.0% versus 0.5%) and severe morbidity (14.1% versus 12.5%) were similar after simultaneous colorectal resection and minor hepatectomy compared with isolated minor hepatectomy (both p > 0.05). For major hepatectomy, simultaneous colorectal resection increased mortality (8.3% versus 1.4%, p < 0.05) and severe morbidity (36.1% versus 15.1%, p < 0.05). Combined severe morbidity after staged resections was lower compared to simultaneous resections (36.1% versus 17.6%, p = 0.05) for major hepatectomy but similar for minor hepatectomy (14.1% versus 10.5%, p > 0.05). Major hepatectomy independently predicted severe morbidity after simultaneous resections [hazard ratio (HR) = 3.4, p = 0.008]. Conclusions Simultaneous colorectal and minor hepatic resections are safe and should be performed for most patients with SCRLM. Due to increased risk of severe morbidity, caution should be exercised before performing simultaneous colorectal and major hepatic resections.     

Hepatic resections for non-colorectal, non-neuroendocrine metastases. Results of 32 hepatectomies in 27 patients

STUDY AIM: Liver resections for metastases are commonly performed in colorectal primary tumors and poorly documented in non colorectal tumors. The aim of this study was to report a series of 32 liver resections in 27 patients for different types of non colorectal, non neuroendocrine liver metastases. PATIENTS AND METHOD: From 1986 to 1997, 27 patients (20 women and 7 men, mean age: 56.8 years) were operated on in the same center for liver metastases. Initial cancer was female genital tract (ovarian and fallopian tube) adenocarcinomas (n = 5), gastrointestinal tract adenocarcinomas (n = 8), sarcomas (n = 8), and miscellaneous cancers (n = 6). Liver resections included atypical resections (n = 9), right hepatectomies (n = 11), extended right hepatectomies (n = 2), left hepatectomies (n = 4) and resections of 2 or 3 segments (n = 6). RESULTS: There was no perioperative death. Postoperative morbidity included 8 complications in seven patients, requiring reintervention in three patients. Follow-up was complete for all patients. Survival rate at one, two and five years was 59, 44 and 29% respectively. The longest median survival time was observed in genital tract adenocarcinomas (27 months), whereas the other types of malignancies had a 13- to 17-month mean survival rate. CONCLUSION: These results are almost similar to those observed in liver resections for colorectal metastases. Some carefully selected patients may benefit from liver resection for non colorectal, non neuro-endocrine metastases.     

Aggressive surgical approach to recurrent tumors after hepatectomy for metastatic spread of colorectal cancer to the liver

BACKGROUND: Liver resection is currently accepted as the only potential cure for patients with metastases of colorectal tumors in the liver. However, cancer will recur in more than 70% of patients. METHODS: In the 7 years to December 1997, 60 patients underwent liver resections for colorectal metastases at our institute. Of these, 20 patients had repeated surgical resections for recurrent disease of the liver and other organs. Another 2 patients had undergone previous hepatectomy elsewhere. The clinical data for these patients were reviewed. RESULTS: The median interval between the 2 resections was 16 months. Eighteen hepatectomies, 6 lung resections, and 1 pancreatoduodenectomy were performed in 22 patients. Operative mortality and complication rates were 0% and 18%, respectively. At a median follow-up of 25 months after repeated resection, the survival rate in these patients was 73% at 2 years (12 of 16 evaluable patients are surviving) and 22% at 5 years (2 of 10 evaluable patients are surviving); the median survival time was 44 months. CONCLUSIONS: Repeated resections for recurrent colorectal metastases yield comparable results to first liver resections in operative mortality and morbidity rates, survival time, and pattern of recurrence. Although the number of patients surviving more than 5 years is still limited, the absence of other proven treatments supports the concept of an aggressive resectional approach for these patients.     

The incidence of positive peritoneal cytology in colon cancer: a prospective randomized blinded trial

Many investigators have attempted to explain the suspected increased incidence of port site metastasis in patients undergoing laparoscopic colorectal resections for cancer with animal models in which cancer is simulated by injection of a tumor slurry into the peritoneal cavity. This approach makes the basic assumption that all patients with colorectal malignancies have viable cancer cells freely circulating within the peritoneal cavity. Recent reports in open colorectal resections have conflicting results. Some suggest that the true incidence is negligible and related to advanced-stage cancers whereas others implicate a much higher incidence. We initiated a prospective blinded trial to establish the true incidence of malignant peritoneal cytology in colorectal cancer. One hundred eight consecutive colon resections underwent conventional peritoneal cytologic evaluation. The patients included those with inflammatory conditions of the colon as well as malignant disease. The cytopathologist was blinded as to the indications for surgery as well as the final pathology result. In only one case--stage IV rectal cancer with peritoneal carcinomatosis--was the cytologic specimen positive. Malignant cytology appears to be an infrequent occurrence and is restricted to advanced-stage cancer.     

Colorectal resection in peripheral New Zealand: workload, outcomes and its future

BACKGROUND: Published Australasian findings on colorectal cancer surgery workload and performance outcomes have been predominantly from urban specialist units. This study defines workload and index markers of surgical quality for colorectal resections carried out in a peripheral teaching hospital of New Zealand. METHODS: All cases of colorectal cancer surgery between 1 June 1997 and 31 May 2000 were included. RESULTS: One hundred and ninety-one colorectal resections for 197 colorectal carcinomas were carried out. Sites of carcinoma were as follows: 57 rectal (29%), 59 sigmoid (30%), 34 descending/transverse (17%) and 47 ascending/caecal (24%). Advanced pathological stage (Dukes' C or metastatic) was diagnosed in 55%. Performance outcome variables for anterior resections were as follows: wound infection, 14%; anastomotic leak rate, 10.5%; local recurrence within 2-5 years, 14%; unplanned reoperation within 30 days, 16%; and perioperative mortality, 3.5%. Performance outcomes for all other colorectal cancer resections were as follows: wound infection, 10%; no anastomotic leaks; local recurrence, 2%; unplanned reoperation, 4%; and mortality, 4.5%. CONCLUSIONS: Workload and performance outcomes of colorectal cancer resection in provincial New Zealand have been defined in this study. A high proportion of patients presenting to Southland Hospital had advanced cancer in the rectum or distal colon. The main clinical indicators of colorectal cancer surgery outcome (mortality, anastomotic leak, wound infection and local recurrence) compare favourably with accepted standards of the time. Workload is adequate to maintain such outcomes. Future colorectal surgery in non-specialized units is important and can achieve good results.     

Trends towards increased use of the laparoscopic approach in colorectal surgery

Aim The aim of the study was to identify the trend towards laparoscopic resection in the practice of one surgeon and to determine whether the default approach to all colorectal procedures could be by means of minimally invasive techniques with an associated low rate of conversion. Method A prospective database of primary colorectal resections under the care of one colorectal surgeon collected between July 2003 and December 2008 was analysed to determine the trend in the use of the laparoscopic approach and the rate of conversion of an intention‐to‐treat policy for laparoscopic procedures. Patients with recurrent rectal or colonic malignancy were excluded from the study. Results A total of 598 patients underwent elective colorectal resection of which 371 (62%) were carried out laparoscopically with a rate of conversion of 3.2%. The proportion of all colorectal resections that were undertaken laparoscopically in the first 1 year was 26% (22/85) (no conversions). This proportion rose to 100% (127/127) in the fifth year of the study of which 4.0% were converted. The introduction of more complex procedures did not have an adverse effect on the trend towards more laparoscopic resections The commencement of a laparoscopic colorectal fellowship in 2006 was associated with a marked increase in the number of laparoscopic cases. Conclusion A conscious decision to make the laparoscopic approach the default for all colorectal resections can be achieved safely with a low conversion rate. This can be achieved within the context of training a ‘novice’ laparoscopic colorectal surgeon.     

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons

Aim The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection. Method A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained. Results Four hundred and twenty‐four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection. Conclusion Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.     

Surgeon experience with laparoscopic-assisted colorectal surgery in Washington State

PURPOSE: To describe the current practice and opinions held by surgeons performing colorectal surgery in Washington regarding laparoscopic colorectal surgery. METHODS: After attempting to identify all surgeons with hospital privileges in colorectal surgery in Washington, a survey was sent to 303 surgeons. The survey asked about the surgeon's practice, volume of colon surgery in the preceding year, the number of laparoscopic colon resections ever performed, the surgeon's opinion on the future practice of laparoscopic colorectal surgery, and whether faced with the personal need to undergo colon resection at the present time, would the surgeon elect to have laparoscopic or open colon resection. RESULTS: In all 170 surveys were returned; 154 returned surveys were from surgeons who had performed at least one colon resection in the preceding year; 53 (34%) respondents had experience with fewer than 20 laparoscopic resections and 83 (55%) have never performed laparoscopic-assisted colectomy (LAC). Only 4 (3%) surgeons had performed more than 50 laparoscopic colon resections. Forty-five percent of respondents indicated that they would currently seek a laparoscopic resection for themselves to treat either a benign condition or an incurable malignancy, and 84% of respondents indicated they would have an open colectomy for a curable malignancy. CONCLUSIONS: The majority of surgeons performing colorectal resections in Washington have limited experience with LAC. Surgeon opinion regarding the role of laparoscopic colorectal surgery in clinical practice is mixed. We suggest a model for proctoring of LAC for surgeons interested in implementing laparoscopic colorectal resection into their practice.     

EARLY FEEDING AFTER ELECTIVE OPEN COLORECTAL RESECTIONS: A PROSPECTIVE RANDOMIZED TRIAL

Background : A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. Methods : Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24–48 h. Results : There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. Conclusion : Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.     

Establishment of a minimally invasive program at a Veterans' Affairs Medical Center leads to improved care in colorectal cancer patients

Background

Despite significant advantages to patients, less than 5% of all colorectal surgeries for cancer are performed laparoscopically. A minimally invasive colorectal cancer program was created in our Veterans' Affairs hospital with the intent of increasing access and improving quality of patient care while maintaining patient safety and oncologic standards.

Methods

Sixty consecutive laparoscopic colorectal cancer resections and 60 age-matched open resections were identified. Our prospective database was queried for demographic, clinical outcomes, and oncologic data.

Results

Patients undergoing laparoscopic resections experienced a shorter hospital stay and a quicker return of bowel function. Both groups had similar intraoperative blood loss and surgical times. Laparoscopic resections achieved equivalent lymph node retrieval and resection completeness compared with open resections. Laparoscopic resections resulted in fewer wounds and fewer complications requiring reoperation.

Conclusions

Establishment of a minimally invasive colorectal cancer program in a Veterans Affairs Medical Center leads to increased access to laparoscopic colorectal resections and improved patient care while maintaining patient safety.     

The learning curve in laparoscopic resections of the colon and rectum: results and considerations

A well-designed learning curve is essential for the success of laparoscopic colorectal surgery for cancer. The aim of this study was to evaluate the results and characteristics of the learning curve in laparoscopic colorectal surgery beginning with benign diseases and eventually going on to include colonic resections for cancer. A total of 60 laparoscopic resections were performed. In the first 33 cases only benign diseases (diverticular disease and polyps) were treated. The next 27 cases included resections for cancer, initially with the following exclusion criteria: obesity, previous abdominal surgery, emergency surgery for occlusion, voluminous tumours or infiltration of surrounding organs. Since January 2002 the only applicable exclusion criteria for laparoscopic resection have been emergency surgery for occlusion and invasion of adjacent organs. The following procedures were performed: 29 left hemicolectomies, 19 sigmoid resections, 7 segmentary resections, 3 abdomino-perineal resections and 2 right hemicolectomies. The conversion rate was 11.6%. The mean length of the segment removed was 21.5 cm. The mean number of lymph nodes harvested (for cancer) was 22.3. Major complications were observed in 3.3% and minor complications in 13.3%. The operative time decreased from a mean of 207 minutes to a mean of 170 minutes in the last group of 20 patients. Laparoscopic resections are safe and give the patient the opportunity to make a rapid recovery with less pain and a better outcome. We suggest performing laparoscopic colorectal resections initially for benign diseases (diverticular disease and polyps). This is needed in order to hone the technique. Resections for cancer can be undertaken only when the surgical team can guarantee an oncologically correct procedure in terms of lymphadenectomy, intraabdominal manipulation and extraction of the diseased segment from the abdomen.     

Efficacy of transversus abdominis plane blocks in laparoscopic colorectal resections

Background  

The increasing use of laparoscopic techniques for colorectal resections means that the issue of postoperative analgesia needs to be reassessed. This nonrandomized comparative study aimed to assess the efficacy of the transversus abdominis plane (TAP) block in laparoscopic colorectal resections.     

110 consecutive laparotomies for hepatic metastasis

From 1978 to 1988, we performed 110 laparotomies for hepatic metastases. With 41 resections for colorectal metastases, the survival was 34% at 3 years. The operative mortality was 7%. With 25 resections for non colorectal liver metastases, the survival was 42% at 1 year, 12% at 3 years. The results, compared with those of literature justify, in the absence of any other potential curative treatment, to remove colorectal liver metastases. For metastases from other tumours, results of resection for endocrine tumours and few sarcomas invite us to an aggressive approach.     

MRSA infections following colorectal surgery in an enhanced recovery programme

Aim The aim of this study was to evaluate the incidence of methicillin‐resistant Staphylococcus aureus (MRSA) infections in a cohort of patients undergoing elective colorectal resections within an enhanced recovery programme. Method A prospective database of all patients undergoing colorectal resections by a single surgical team over a 3.5‐year period was reviewed. Demographics including age, gender, body mass index, American Society of Anesthesiologists classification, type of surgery (abdominal or pelvic) and whether or not the procedure was laparoscopic or open were analysed. All patients were screened preoperatively and postoperatively and on discharge for MRSA. Patients found preoperatively to be MRSA positive were excluded from the study. Results In all, 186 patients underwent colorectal resection over the time reviewed. There were 113 laparoscopic resections, 70 open resections and three laparoscopic converted to open resections. Five patients (2.7%) were found to be MRSA positive postoperatively. All of these had open rather than laparoscopic surgery (P < 0.01). Length of stay for patients that had MRSA infections was significantly longer than those remaining MRSA free (P < 0.05). Conclusion These results suggest that patients who successfully undergo laparoscopic colorectal resections within an enhanced recovery programme have a lower incidence of postoperative MRSA infections.     

Surgical treatment of liver metastases from colorectal cancer

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.     

The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections

Background  

Enhanced recovery after surgery (ERAS) programs can accelerate recovery and shorten the hospital stay after colorectal resections. The RAPID (remove, ambulate, postoperative analgesia, introduce diet) protocol is a simplified ERAS program that consists of a simplified, user-friendly single-page pro forma schedule. This study aimed to evaluate the impact of the RAPID protocol on patients undergoing both laparoscopic and open colorectal resections in two specialized colorectal units.     

Open resection for colorectal cancer

In the UK open colorectal surgery is becoming less frequent in many centres where laparoscopic colorectal resection is being offered to most patients. However, the principles governing surgery for colorectal cancers remain the same in both modalities of treatment. The purpose of this article is to give the reader an overview of the types of operation used and the factors that are considered in approaching open colorectal cancer resections.     

Repeat hepatic resections for metastatic colorectal cancer.

OBJECTIVE: The authors weighed the risks and benefits of repeat liver resections for colorectal metastatic disease. METHOD: In the 6-year period between January 1985 and June 1991, 499 patients underwent liver resections for colorectal metastases at the Memorial Sloan-Kettering Cancer Center. Of these, 25 patients had repeat surgical resections for isolated recurrent disease to the liver. The clinical data for these patients were reviewed. RESULTS: The median interval between the two resections was 11 months. There were no perioperative deaths, and the complication rate was 28%. Median follow-up after the second liver resection is 19 months, with median survival of 17 months for nonsurvivors. Although the median survival after the second resection is 30 months, 20 of the 25 patients have had recurrences with a median disease-free interval of only 9 months. No characteristic of primary or metastatic disease predicted outcome, including time between presentation of the primary and development of liver metastases, disease-free interval after the first liver resection, and bilobar liver involvement. CONCLUSIONS: Although repeat liver resections can be performed safely and improves survival, the likelihood of cure from such resection therapy is low. This likelihood of further recurrences encourage studies of adjuvant or alternative treatments of this population.     

Hand-Assisted Laparoscopic (HAL) Multiple Segmental Colorectal Resections: Are They Feasible and Safe?

The objective of this study was to evaluate the short-term outcomes of synchronous hand-assisted laparoscopic (HAL) segmental colorectal resections. The surgical options for synchronous colonic pathology include extensive colonic resection with single anastomosis, multiple synchronous segmental resections with multiple anastomoses, or staged resections. Traditionally, multiple open, synchronous, segmental resections have been performed. There is a lack of data on HAL multiple segmental colorectal resections. A retrospective chart review was compiled on all patients who underwent HAL synchronous segmental colorectal resections by all the colorectal surgeons from our Group during the period of 1999 to 2014. Demographics, operative details, and short-term outcomes are reported. During the period, 9 patients underwent HAL synchronous multiple segmental colorectal resections. There were 5 women and 4 men, with median age of 54 (24–83) years and median BMI of 24 (19.8–38.7) kg/m². Two patients were on long-term corticosteroid therapy. The median operative time was 210 (120–330) minutes and median operative blood loss was 200 (75–300) mLs. The median duration for return of bowel function was 2 days and the median length of stay was 3.5 days. We had 2 minor wound infections. There were no deaths. Synchronous segmental colorectal resections with anastomoses using the hand-assisted laparoscopic technique are safe. Early conversion to open and use of stomas are advisable in challenging cases.Key words: Hand assisted laparoscopic surgery, Synchronous, Colorectal anastomosesSynchronous colonic pathology affecting distant colonic segments, although uncommon, poses a management dilemma. The surgical options include extensive resections with single anastomosis or multiple segmental resections with synchronous multiple anastomoses. Extended colonic resections may alter bowel function and affect quality of life.¹ On the other hand, the risk of anastomotic leak maybe increased with multiple colonic anastomoses. Studies have shown that open synchronous multiple colonic anastomoses are safe.^2,3Traditionally, multiple segmental resections have been performed with open surgery. Hand-assisted laparoscopic (HAL) colectomy has an edge over open surgery with decreased postoperative pain, length of stay and wound, and pulmonary complications.⁴ The aim of this study is to evaluate the short-term outcomes in a cohort of patients who underwent synchronous HAL multiple segmental colorectal resections.