Faculty Bibliography

BACKGROUND:As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS:Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT:Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS:MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

BACKGROUND:Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment. METHODS:A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials. RESULTS:39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed. CONCLUSIONS:LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.

Wearable devices are increasingly utilised to monitor patients perioperatively, allowing for continuous data collection and early complication detection. There is considerable variability in the types and usage settings of wearables, particularly within colorectal surgery. To address this, a scoping review was conducted to investigate current utilisation of wearable devices in colorectal surgery. A systematic search across MEDLINE and Embase was conducted following PRISMA Scoping Review guidelines. Results were synthesised narratively, categorised by perioperative phase (preoperative; postoperative; combination), and supplemented with descriptive statistics and tables. Out of 1525 studies initially identified, 20 were included, reporting data on 10 different wearable devices. Use of wearable devices varied across settings with those used preoperatively tending to focus on baseline physical status or prehabilitation, while postoperative use centred around monitoring and identification of complications. Wearable devices can enhance perioperative monitoring, enable proactive interventions, and promote personalised care for improved patient outcomes in colorectal surgery.

The incidences of anogenital HPV-related cancers in women are on the rise; this is especially true for anal cancer. Medical societies are now beginning to recommend anal cancer screening in certain high-risk populations, including high-risk women with a history of genital dysplasia. The aim of this study is to investigate national anogenital HPV cancer trends as well as the role of demographics, deprivation, and ethnicity on anogenital cancer incidence in England, in an attempt to better understand this cohort of women which is increasingly affected by anogenital HPV-related disease. Demographic data from the Clinical Outcomes and Services Dataset (COSD) were extracted for all patients diagnosed with anal, cervical, vulval and vaginal cancer in England between 2014 and 2020. Outcomes included age, ethnicity, deprivation status and staging. An age over 55 years, non-white ethnicity and high deprivation are significant risk factors for late cancer staging, as per logistic regression. In 2019, the incidences of anal and vulval cancer in white women aged 55-74 years surpassed that of cervical cancer. More needs to be done to educate women on HPV-related disease and their lifetime risk of these conditions.

OBJECTIVE:To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA]. BACKGROUND:Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials. METHODS:Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs. RESULTS:The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials. CONCLUSIONS:Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.

Rectal tumors extending beyond the total mesorectal excision (TME) plane (beyond-TME) require particular multidisciplinary expertise and oncologic considerations when planning treatment. Imaging is used at all stages of the pathway, such as local tumor staging/restaging, creating an imaging-based "roadmap" to plan surgery for optimal tumor clearance, identifying treatment-related complications, which may be suitable for radiology-guided intervention, and to detect recurrent or metastatic disease, which may be suitable for radiology-guided ablative therapies. Beyond-TME and exenterative surgery have gained acceptance as potentially curative procedures for advanced tumors. Understanding the role, techniques, and pitfalls of current imaging techniques is important for both radiologists involved in the treatment of these patients and general radiologists who may encounter patients undergoing surveillance or patients presenting with surgical complications or intercurrent abdominal pathology. This review aims to outline the current and emerging roles of imaging in patients with beyond-TME and recurrent rectal malignancy, focusing on practical tips for image interpretation and surgical planning in the beyond-TME setting. Keywords: Abdomen/GI, Rectum, Oncology © RSNA, 2024.

Rectal examination through proctoscopy or rigid sigmoidoscopy is a common investigation in clinical practice. It is an important diagnostic tool for the workup and management of anorectal pathologies. Performing the examination can be daunting not only for patients but also for junior doctors. There are associated risks with the procedure, such as pain, diagnostic failure, and perforation of the bowel. Simulation-based training is recognised as an important adjunct in clinical education. It allows students and doctors to practice skills and techniques at their own pace in a risk-free environment. These skills can then be transferred to and developed further in clinical practice. There is extensive research published regarding the role of simulation-based training in endoscopy, however, we identified no published study regarding simulation-based training in rigid sigmoidoscopy or proctoscopy. This study aims to establish the initial face, content, and construct validity of a tool-based visual anorectal examination advanced simulator model for proctoscopy and rigid sigmoidoscopy. This innovative, highly realistic simulated environment aims to enhance the training of healthcare professionals and improve the efficiency of detecting and diagnosing distal colorectal disease.

Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.

BACKGROUND:The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process. METHODS AND ANALYSIS/METHODS:In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document. REGISTRATION DETAILS/BACKGROUND:The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

Heparin and derivatives are commonly used for thrombophylaxis in surgical colorectal cancer (CRC) patients. Recent studies have suggested that, besides its protective effect on the incidence of venous thromboembolism, heparin has an anti-cancer effect. The aim of this review was to explore the literature and report the antineoplastic effect of heparin and derivatives on CRC. MEDLINE and EMBASE databases were searched for relevant articles. Nineteen studies were included (n = 19). Fifteen were lab studies conducted in vivo or in vitro on CRC cell lines and/or mice (n = 15). Four were in vivo clinical studies (n = 4). CRC tumor growth was reduced by 78% in one study, (p < 0.01), while tumorigenesis was suppressed in heparin-treated mice in seven studies. A high dose of low molecular weight heparin for extended duration significantly reduced post-operative VEGF, suggesting that such a regime may inhibit tumor angiogenesis and distant metastasis. A randomized trial demonstrated the antineoplastic effect of nadroparin as the 6 month survival in palliative patients increased. Another study has reported that disease-free survival of CRC patients was not affected by a similar tinzaparin regime. The anti-cancer properties of heparin and derivatives are promising, especially in lab studies. Further clinical trials are needed to investigate the anti-cancer benefit of heparin on CRC.