Experiences of a “COVID protected” robotic surgical centre for colorectal and urological cancer in the COVID-19 pandemic

AbstractThe recent COVID-19 pandemic led to the cancellation of elective surgery across the United Kingdom. Re-establishing elective surgery in a manner that ensures patient and staff safety has been a priority. We report our experience and patient outcomes from setting up a “COVID protected” robotic unit for colorectal and renal surgery that housed both the da Vinci Si (Intuitive, Sunnyvale, CA, USA) and the Versius (CMR Surgical, Cambridge, UK) robotic systems. “COVID protected” robotic surgery was undertaken in a day-surgical unit attached to the main hospital. A standard operating procedure was developed in collaboration with the trust COVID-19 leadership team and adapted to national recommendations. 60 patients underwent elective robotic surgery in the initial 10-weeks of the study. This included 10 colorectal procedures and 50 urology procedures. Median length of stay was 4 days for rectal cancer procedures, 2 days less than prior to the COVID period, and 1 day for renal procedures. There were no instances of in-patient coronavirus transmission. Six rectal cancer patients waited more than 62 days for their surgery because of the initial COVID peak but none had an increase T-stage between pre-operative staging and post-operative histology. Robotic surgery can be undertaken in “COVID protected” units within acute hospitals in a safe way that mitigates the increased risk of undergoing major surgery in the current pandemic. Some benefits were seen such as reduced length of stay for colorectal patients that may be associated with having a dedicated unit for elective robotic surgical services.

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The Incidence and Disease Course of Perianal Crohn’s Disease: A Danish Nationwide Cohort Study, 1997–2015

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjaa118 ◽

2020 ◽

Author(s):

M D Wewer ◽

M Zhao ◽

A Nordholm-Carstensen ◽

P Weimers ◽

J B Seidelin ◽

...

Keyword(s):

Rectal Cancer ◽

Crohn’S Disease ◽

Crohn's Disease ◽

Cox Regression ◽

Major Surgery ◽

Disease Course ◽

Cox Regression Analysis ◽

Perianal Crohn’S Disease ◽

Increased Risk ◽

Perianal Crohn's Disease

Abstract Background and Aims Perianal Crohn’s disease [CD] places a considerable burden on patients’ quality of life and is complex to treat. Despite its impact and high frequency, few studies have investigated the incidence and disease course of perianal CD. The aim of this study was to assess the incidence and disease course of perianal CD in adult patients throughout a 19-year period. Methods The cohort comprised all individuals aged 18 years or older who were diagnosed with CD in Denmark between January 1, 1997, and December 31, 2015, according to the National Patient Registry [NPR]. Results A total of 1812 [19%] out of 9739 patients with CD were found to have perianal CD. Perianal fistulas were the most common manifestation, accounting for 943 [52%] cases. The incidence of perianal CD remained stable over time. Patients with perianal CD were found to have an increased risk of undergoing major abdominal surgery compared with patients without perianal CD (hazard ratio: 1.51, 95% confidence interval [CI]: 1.40 to 1.64, p <0.001) in a multivariate Cox regression analysis. The incidence rate ratios of anal and rectal cancer in perianal CD patients were 11.45 [95% CI: 4.70 to 27.91, p <0.001] and 2.29 [95% CI: 1.25 to 4.20, p = 0.006], respectively, as compared with non-IBD matched controls. Conclusions In this nationwide study, 19% of CD patients developed perianal disease. Patients with perianal CD were at increased risk of undergoing major surgery compared with non-perianal CD patients. The risk of anal and rectal cancer was increased in patients with perianal CD compared with non-IBD matched controls. Podcast This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast

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Update on Direct Oral AntiCoagulants (DOACs)

Phlebologie ◽

10.1055/s-0038-1657856 ◽

2018 ◽

Vol 47 (03) ◽

pp. 137-145

Author(s):

C. Rosenthal ◽

C. von Heymann ◽

J. Koscielny

Keyword(s):

Elective Surgery ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Patient Characteristics ◽

Clinical Decision ◽

Major Surgery ◽

Preoperative Treatment ◽

Risk Of Bleeding ◽

Increased Risk ◽

Meta Analyses

SummaryRecent findings require an update of previous recommendations for the perioperative use of Direct Oral AntiCoagulants (DOACs). A break in preoperative treatment of 24-96 hours is recommended based on the pharmacokinetic profiles of DOACs and depends on individual patient characteristics, their renal and possibly liver function, and their surgery-related risk of bleeding. In cases of renal or hepatic insufficiency, whether to extend the preoperative interruption of IIa- and Xa-inhibitors is a clinical decision that must be reached on an individual patient basis. In cases of epidural or spinal anaesthesia, more conservative pausing-intervals are recommended due to the risk of persistent neurologic deficits (e.g., paraplegia) following the development of spinal subdural and epidural haematomas. Elective surgery should be postponed according to these recommendations. Preoperative “bridging” with LMWH (more precisely referred to as “switching”) should be omitted due to a significantly increased risk of bleeding. In addition, the incidence of perioperative thromboembolic risks, such as DVT, PE, and stroke, are no different whether interruption or „switching” is undertaken. Postoperatively, the DOACs can be reinstituted within the first 24 hours. In cases of major surgery or if there is a higher risk of bleeding, resumption of DOACS should only begin after 24-72 hours. In patients with an elevated thromboembolic risk, transient postoperative LMWH administration can be recommended during this period.Interaction of DOACs with other drugs usually occurs during the absorption, transport and elimination of these drugs. Therefore, substance-specific restrictions and recommendations should be observed during these times. In everyday clinical practice, webbased, independent information portals on drug-interactions are very helpful in providing safe and rapid information about potential interactions when DOACs are used in combination with other drugs, especially during perioperative management.Non-adherence to medications is a worldwide problem that has dangerous and costly consequences. Present data suggest that persistence is the primary factor that supports adherence. Despite the adherence data presented in the DOACS approval studies (e.g., persistence in the treatment of acute venous thromboembolism has been reported to be between 94-99%), the first registries and meta-analyses provide sobering results regarding the incidence of persistence and the success rate of interventions designed to improve adherence with DOACs in cases of long-term usage.Nachdruck aus und zu zitieren als: Hämostaseologie 2017; 37: 267–275 https://doi.org/10.5482/HAMO-16-10-1657856

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Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0280 ◽

2017 ◽

Vol 99 (2) ◽

pp. 113-116 ◽

Cited By ~ 9

Author(s):

MR Boland ◽

I Reynolds ◽

N McCawley ◽

E Galvin ◽

S El-Masry ◽

...

Keyword(s):

Rectal Cancer ◽

Risk Factor ◽

Length Of Stay ◽

Hospital Stay ◽

Independent Risk Factor ◽

Elective Surgery ◽

Cancer Surgery ◽

Rectal Cancer Surgery ◽

Major Morbidity ◽

Grade Iii

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I–IV) and the secondary outcomes were length of stay and major morbidity (Clavien–Dindo grade III–IV). RESULTS Over a 2-year period (2012–2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200–9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien–Dindo grade III–IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson’s correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

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614 Elective Bariatric and Metabolic Surgery in United Kingdom During the Coronavirus Pandemic

British Journal of Surgery ◽

10.1093/bjs/znab259.186 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

R Mamidanna ◽

A Askari ◽

K Patel ◽

M T Adil ◽

V Jain ◽

...

Keyword(s):

Metabolic Surgery ◽

Elective Surgery ◽

Weight Loss Surgery ◽

Revisional Surgery ◽

Standard Operating Procedure ◽

Number Of Patients ◽

Increased Risk ◽

Standard Operating ◽

Bariatric Patients ◽

The Uk

Abstract Aim Elective Bariatric and Metabolic Surgery (BMS) was halted in the UK during the first wave of the Coronavirus (COVID-19) pandemic. Obesity is a predictor of poor outcome in those infected with this virus. This study reports our experience resuming elective weight loss surgery safely amidst the pandemic. Method Guidance from national bodies (BOMSS/NICE) were reviewed and a Standard Operating Procedure (SOP) was drafted to accommodate local considerations. Data were prospectively collected on patients undergoing BMS following commencement of elective surgery after the first national lockdown. Results A total of 50 patients underwent BMS at our institution within six weeks of resuming the services. The median age was 41 years old and BMI was 43.8(IQR 40.0-48.8 kg/m2). Equal number of patients underwent laparoscopic Sleeve Gastrectomy (SG) and Roux en-Y Gastric Bypass (RYGB). Of these, 9 patients (18%) had revisional surgery and 48 patients (96%) were discharged within 24 hours of their surgery. The rate of readmission within thirty days of surgery was 6% (n = 3) and 1 patient returned to theatre with an obstruction proximal to the jejuno-jenunal anastomosis. None of the patients exhibited symptoms or tested positive for the COVID-19 virus. Conclusions With appropriate precautions and protocols, it is feasible and safe to resume BMS, with no increased risk to bariatric patients during the COVID-19 pandemic. This is particularly encouraging for other units in UK to offer BMS after the current lockdown.

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Comparison of preoperative screening tools predicting postoperative complications in oncogeriatric surgical patients.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.9557 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 9557-9557

Author(s):

Monique Huisman ◽

Barbara Van Leeuwen ◽

Giampaolo Ugolini ◽

Isacco Montroni ◽

Cesare Stabilini ◽

...

Keyword(s):

Solid Tumors ◽

Preventive Measures ◽

Elective Surgery ◽

Screening Tools ◽

Surgical Patients ◽

Major Surgery ◽

Time Saving ◽

Increased Risk ◽

Operative Complications ◽

Post Operative Complications

9557 Background: In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome in order to effectively implement preventive measures and to improve outcome in this population. There is need for a time saving and efficient screening tool. Our aim was to determine the predictive ability of the Mini Mental State Examination (MMSE), Brief Fatigue Inventory (BFI) and Timed “Up & Go” (TUG) concerning the occurrence of a major post-operative complication in a series of elderly patients undergoing elective surgery for solid tumors. Methods: In an international cohort, 329 patients ≥70years undergoing elective surgery for solid tumors were prospectively included. Primary endpoint was the incidence of a major complication during the first 30 days after surgery. Pre-operatively the MMSE, BFI and TUG were scored. TUG depicts the time needed to stand up from a chair, walk 3 meters, turn around, walk back and sit down. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Results: The majority of patients underwent major surgery (n=219; 66.6%). A total of 71 (22.1%) patients experienced major complications. TUG, MMSE and BFI, adjusted for center, gender and minor or major surgery, were independent predictors of the occurrence of major post-operative complications (see Table). Conclusions: Screening tools are able to predict major post-operative complications in onco-geriatric surgical patients. TUG is most specific in identifying patients at risk and could be considered to allocate preventive measures effectively. [Table: see text]

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Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay

BMC Surgery ◽

10.1186/s12893-021-01166-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Riccardo Lemini ◽

Iktej S. Jabbal ◽

Krystof Stanek ◽

Shalmali R. Borkar ◽

Aaron C. Spaulding ◽

...

Keyword(s):

Rectal Cancer ◽

Length Of Stay ◽

Cancer Patients ◽

Open Surgery ◽

Elective Surgery ◽

Health Care Administration ◽

Hospital Inpatient ◽

Southwest Florida ◽

Permanent Stoma ◽

Rectal Cancer Treatment

Abstract Background This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility. Methods Rectal cancer patients who underwent elective surgery between January 2015 and December 2018 were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients. Results Of 2630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, advanced age, having open surgery, residence in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p < 0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p < 0.001). Conclusions Patients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Having permanent stoma was higher in patients living in South West Florida, patients with Medicaid insurance, and in the uninsured. Additionally, the payer type significantly affected the length of stay.

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Update on Direct Oral AntiCoagulants (DOACs)

Hämostaseologie ◽

10.5482/hamo-16-10-0041 ◽

2017 ◽

Vol 37 (04) ◽

pp. 267-275 ◽

Cited By ~ 3

Author(s):

Christoph Rosenthal ◽

Christian von Heymann ◽

Jürgen Koscielny

Keyword(s):

Elective Surgery ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Patient Characteristics ◽

Clinical Decision ◽

Major Surgery ◽

Preoperative Treatment ◽

Risk Of Bleeding ◽

Increased Risk ◽

Meta Analyses

SummaryRecent findings require an update of previous recommendations for the perioperative use of Direct Oral AntiCoagulants (DOACs). A break in preoperative treatment of 24–96 hours is recommended based on the pharmacokinetic profiles of DOACs and depends on individual patient characteristics, their renal and possibly liver function, and their surgery-related risk of bleeding. In cases of renal or hepatic insufficiency, whether to extend the preoperative interruption of IIa- and Xa-inhibitors is a clinical decision that must be reached on an individual patient basis. In cases of epidural or spinal anaesthesia, more conservative pausing-intervals are recommended due to the risk of persistent neurologic deficits (e.g., paraplegia) following the development of spinal subdural and epidural haematomas. Elective surgery should be postponed according to these recommendations. Preoperative “bridging” with LMWH (more precisely referred to as „switching”) should be omitted due to a significantly increased risk of bleeding. In addition, the incidence of perioperative thromboembolic risks, such as DVT, PE, and stroke, are no different whether interruption or “switching” is undertaken. Postoperatively, the DOACs can be reinstituted within the first 24 hours. In cases of major surgery or if there is a higher risk of bleeding, resumption of DOACS should only begin after 24–72 hours. In patients with an elevated thromboembolic risk, transient postoperative LMWH administration can be recommended during this period.Interaction of DOACs with other drugs usually occurs during the absorption, transport and elimination of these drugs. Therefore, substance- specific restrictions and recommendations should be observed during these times. In everyday clinical practice, webbased, independent information portals on drug-interactions are very helpful in providing safe and rapid information about potential interactions when DOACs are used in combination with other drugs, especially during perioperative management.Non-adherence to medications is a worldwide problem that has dangerous and costly consequences. Present data suggest that persistence is the primary factor that supports adherence. Despite the adherence data presented in the DOACS approval studies (e.g., persistence in the treatment of acute venous thromboembolism has been reported to be between 94–99%), the first registries and meta-analyses provide sobering results regarding the incidence of persistence and the success rate of interventions designed to improve adherence with DOACs in cases of long-term usage.

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1441 Real-World Comparison of Curative Open, Laparoscopic and Robotic Resections for Sigmoid and Rectal Cancer - Single Center Experience

British Journal of Surgery ◽

10.1093/bjs/znab259.798 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

S. Akhter Ansari ◽

M Ahsan Javed ◽

F Hedayat ◽

C Harris ◽

A Sheikh

Keyword(s):

Rectal Cancer ◽

Lymph Node ◽

Robotic Surgery ◽

Length Of Stay ◽

Anal Verge ◽

Sphincter Preservation ◽

Rectal Cancer Surgery ◽

Neoadjuvant Radiotherapy ◽

Lymph Node Yield ◽

Surgery Group

Abstract Aim There is an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. The aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. Method One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons, using a standardized technique, between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Results Median age of population was 68 years (IQR 59-73), majority (68%) were males. Median distance from anal verge in robotic surgery group was 8 cm, compared to 15 and 14.5 cm in the open and laparoscopic groups respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7 cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Conclusions Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.

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Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

Nature Reviews Nephrology ◽

10.1038/s41581-021-00418-2 ◽

2021 ◽

Author(s):

John R. Prowle ◽

Lui G. Forni ◽

Max Bell ◽

Michelle S. Chew ◽

Mark Edwards ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury ◽

Adverse Outcomes ◽

Baseline Risk ◽

Major Surgery ◽

Increased Risk

AbstractPostoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.

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Difference in surgical outcomes of rectal cancer by study design: meta-analyses of randomized clinical trials, case-matched studies, and cohort studies

BJS Open ◽

10.1093/bjsopen/zraa067 ◽

2021 ◽

Vol 5 (2) ◽

Author(s):

N Hoshino ◽

T Sakamoto ◽

K Hida ◽

Y Takahashi ◽

H Okada ◽

...

Keyword(s):

Rectal Cancer ◽

Laparoscopic Surgery ◽

Robotic Surgery ◽

Cohort Studies ◽

Anastomotic Leakage ◽

Study Design ◽

Randomized Clinical Trials ◽

Postoperative Mortality ◽

Resection Margins ◽

Meta Analyses

Abstract Background RCTs are considered the standard in surgical research, whereas case-matched studies and propensity score matching studies are conducted as an alternative option. Both study designs have been used to investigate the potential superiority of robotic surgery over laparoscopic surgery for rectal cancer. However, no conclusion has been reached regarding whether there are differences in findings according to study design. This study aimed to examine similarities and differences in findings relating to robotic surgery for rectal cancer by study design. Methods A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane CENTRAL to identify RCTs, case-matched studies, and cohort studies that compared robotic versus laparoscopic surgery for rectal cancer. Primary outcomes were incidence of postoperative overall complications, incidence of anastomotic leakage, and postoperative mortality. Meta-analyses were performed for each study design using a random-effects model. Results Fifty-nine articles were identified and reviewed. No differences were observed in incidence of anastomotic leakage, mortality, rate of positive circumferential resection margins, conversion rate, and duration of operation by study design. With respect to the incidence of postoperative overall complications and duration of hospital stay, the superiority of robotic surgery was most evident in cohort studies (risk ratio (RR) 0.83, 95 per cent c.i. 0.74 to 0.92, P < 0.001; mean difference (MD) –1.11 (95 per cent c.i. –1.86 to –0.36) days, P = 0.004; respectively), and least evident in RCTs (RR 1.12, 0.91 to 1.38, P = 0.27; MD –0.28 (–1.44 to 0.88) days, P = 0.64; respectively). Conclusion Results of case-matched studies were often similar to those of RCTs in terms of outcomes of robotic surgery for rectal cancer. However, case-matched studies occasionally overestimated the effects of interventions compared with RCTs.

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