Faculty Bibliography

BACKGROUND:Colorectal cancer (CRC) is the fourth most common cancer in the United Kingdom. The five-year survival rate from CRC is only 10% when discovered at a late stage, but can exceed 90% if diagnosed early. Symptoms related to CRC can be non-specific, and therefore the decision to refer for a colonoscopy can be challenging. Breath analysis potentially offers a simple and quick method to detect CRC specific volatile organic compounds (VOCs) in breath. This protocol describes the COBRA2 study which aims to develop and validate the clinical prediction model (CPM) in the detection of CRC based on the breath test. An exploratory comparison between the breath test and faecal immunochemical test (FIT) will also be carried out to assess whether combining both tests improves diagnostic performance. METHODS:The COBRA2 study is a multicentre, case-control development and validation study. Breath samples will be collected from participants attending hospital for a planned colonoscopy (control group) or from participants with histologically confirmed colorectal adenocarcinoma (CRC group). A total of 720 participants (470 controls, 250 CRC) will be recruited. All participants will maintain a clear fluid diet for a minimum of 4-6 h prior to sampling, which will take place at outpatient clinics to avoid bowel preparation. The FIT result will be recorded where available. Breath samples will be analysed using gas chromatography-mass spectrometry to identify the VOCs present. Relationships between VOCs of interest and presence of CRC will be explored, and the CPM will be developed using statistical and machine learning methods. We will also assess whether incorporating FIT into the CPM improves diagnostic performance. The CPM will be subsequently validated in an independent sample of up to 250 participants (125 controls, 125 CRC) using the same case-control design and the potential clinical utility of decision rules for triaging will be assessed. If successful, broad validation in an unselected target population of symptomatic patients is required. DISCUSSION/CONCLUSIONS:The non-invasive breath test may provide direct patient benefit through earlier and accurate detection of CRC, and higher patient acceptability. It can help ensure timely secondary care referral, potentially translating to improved curative treatment and survival for patients. TRIAL REGISTRATION/BACKGROUND:The study is registered with ClinicalTrials.gov (NCT05844514).

BACKGROUND:Complete mesocolic excision (CME) is a surgical technique that aims to improve oncological outcomes of right-sided colon cancer resections. However, CME's technical complexity, surgical risks, and need for specialized training, present challenges. Also, variations in technical aspects and implementation lead to inconsistent outcomes. OBJECTIVE:To develop evidence-informed clinical practice recommendations on complete mesocolic excision for right-sided colon cancer, aiming to address whether laparoscopic CME should be preferred over standard laparoscopic right hemicolectomy for right-sided colon cancer. METHODS:The present guideline adheres to GRADE, AGREE-S, and Cochrane standards, using MAGICapp for development. The steering group included colorectal and general surgeons, supported by a Guidelines International Network-certified lead guideline developer, trainee methodologists, systematic reviewers and statisticians. The guideline panel included surgeons, oncologists, a pathologist, and a patient partner. It provides recommendations based on a linked systematic review, appraisal of benefits and harms, the certainty of the evidence, patient values and preferences, acceptability, feasibility, use of resources, and equity. RESULTS:A conditional recommendation is issued in favor of CME for patients undergoing right hemicolectomy for right-sided colon cancer where expertise is available, based on low-to-moderate certainty evidence. The panel suggests CME is acceptable to stakeholders and feasible, despite potential equity issues due to variable expertise availability. There is insufficient evidence to recommend CME based on tumor location or cancer stage. A conditional recommendation means that the majority of well-informed patients, surgeons and other stakeholders, would opt for the recommended course of action, but discussion of relevant benefits and harms is advised prior to decisions. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/EaG1dL . CONCLUSIONS:This guideline provides evidence-informed recommendations on the management of right-sided colon cancer, developed in line with the highest quality methodological and reporting standards, and informed by an interdisciplinary panel of stakeholders.

BACKGROUND:Complete mesocolic excision (CME) is a surgical approach for right-sided colon cancer, involving the resection of the primary tumour along with an intact mesocolon, central vascular ligation, and exposure of the superior mesenteric vein. It has been postulated to improve oncologic outcomes such as disease-free survival and reduce local recurrence compared to standard right colectomy. However, the clinical benefits are still debated. OBJECTIVE:This systematic review and meta-analysis, sponsored by the European Association for Endoscopic Surgery, aims to compare the oncologic outcomes of CME with standard right colectomy for right-sided colon cancer, with the ultimate objective to inform clinical practice recommendations. METHODS:We followed the PRISMA 2020 reporting standards. A comprehensive literature search was conducted to identify relevant studies published from 2008 onwards, focusing on randomised trials and matched cohort studies comparing CME with standard right hemicolectomy. The GRADE methodology was used to assess the certainty of evidence, and minimal important differences were calculated to inform clinical relevance. RESULTS:Thirteen studies, amongst which three randomised trials, were included. No difference was found between CME and standard colectomy in terms of 30-day mortality, major peri-operative morbidity, or major blood loss. However, patients who underwent CME showed improved overall survival (HR = 0.67, 95%CI [0.48 - 0.93], low certainty of evidence) and disease-free survival (HR = 0.78, 95% CI [0.63 - 0.96], low certainty of evidence) compared to those who underwent standard colectomy, though certainty of the evidence was low due to the high risk of bias in the observational studies. CONCLUSION/CONCLUSIONS:Complete mesocolic excision may offer survival benefits over standard right colectomy for right-sided colon cancer. However, the evidence remains of low certainty, mainly due to the predominance of observational data with significant risk of bias. Future high-quality randomized trials are needed to confirm these findings and standardize surgical techniques to reduce heterogeneity and improve clinical outcomes.

PURPOSE/OBJECTIVE:This study aims to assess the quality of educational surgical videos for robotic total mesorectal excision (TME), across widely used open-source platforms, using a newly designed quality assessment checklist. METHODS:The checklist was developed by using existing society guidelines, such as the European Academy of Robotic Colorectal Surgery, comprising four key sections: (i) usability of the platform, (ii) video component, (iii) intraoperative techniques and (iv) other information (including case presentation and outcomes). Videos were identified using the search terms 'Robotic TME' from surgical education platforms (WebSurg, C-SATS and Touch Surgery) and YouTube, between January 2016 and July 2024. All videos displaying robotic TME were reviewed and scored using the quality assessment tool (/12), and the videos across the platforms were subsequently compared. RESULTS:A total of 113 videos were scored using the checklist: 63 surgical education platform (10 WebSurg and 53 C-SATS) and 50 YouTube videos. The total median checklist score achieved by WebSurg (9 [IQR 8-9] and YouTube videos (8 [IQR 7-10]) was significantly higher than CSAT-S videos (4 [IQR 4-5]; p < 0.001). The usability of platform scores for YouTube was significantly higher than WebSurg and C-SATS videos (p < 0.001). Scores for video components, intraoperative techniques and other information were higher across WebSurg and YouTube videos when compared to C-SATS (p < 0.001); however, there was no significant difference between WebSurg and YouTube for each domain. CONCLUSION/CONCLUSIONS:The overall educational quality of online robotic TME videos was found to be generally heterogeneous, with WebSurg and YouTube videos demonstrating higher scores based on the checklist. A new quality assessment tool has been proposed for robotic TME videos, which has the potential to improve the reliability and value of published video research.

BACKGROUND:Patients with ileocolic Crohn's disease often require surgery that can result in temporary stoma formation. Stomas are associated with a morbidity and can negatively impact quality of life. This study aimed to investigate the short-term (6-month) and mid-term (18-month) outcomes of intended temporary stomas in patients with Crohn's disease. METHODS:A trainee-led, international multicentre, retrospective study was conducted on all patients who underwent surgery for Crohn's disease in collaborating centres over 4 years (2017-2020). The primary outcome was the proportion of patients with Crohn's disease who underwent stoma reversal surgery by 6- and 18-month postoperative follow-up. Secondary outcomes included: the time interval between formation and reversal of stoma and predictors for non-reversal and stoma-related morbidity (postoperative complications, related readmissions and complications due to stoma reversal surgery). RESULTS:A total of 401 patients underwent stoma formation for Crohn's disease over the 4 years across the 44 collaborating centres. The temporary stomas had been reversed in 30.2% of patients at the 6-month and 56.9% at the 18-month follow-up. Reasons for non-reversal included ongoing medical treatment for Crohn's disease (respectively 6-month and 18-month: 37.6%, 39.3%), patient unfit for surgery (respectively 6-month and 18-month: 14.5%, 16.8%), patient preference (respectively 6-month and 18-month: 12.1%, 20.2%) and due to waiting lists (respectively 6-month and 18-month: 12.1%, 8.1%). Overall, 63.3% of patients had a temporary stoma reversed with a median time interval of 6 months. The stoma-related overall morbidity rate was 29.4%. CONCLUSIONS:A large proportion of temporary stomas for Crohn's disease were not reversed at 6 and 18 months following initial surgery. Patients are exposed to the risk of non-reversal and risk of developing stoma complications for significantly longer intervals of time and, in some cases, indefinitely.

INTRODUCTION/BACKGROUND:The rapid adoption of robotic surgical systems has overtook the development of standardized training and competency assessment for surgeons, resulting in an unmet educational need in this field. This systematic review aims to identify the essential components and evaluate the validity of current robotic training curricula across all surgical specialties. METHODS:A systematic search of MEDLINE, EMBASE, Emcare, and CINAHL databases was conducted to identify the studies reporting on multi-specialty or specialty-specific surgical robotic training curricula, between January 2000 and January 2024. We extracted the data according to Kirkpatrick's curriculum evaluation model and Messick's concept of validity. The quality of studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS:From the 3687 studies retrieved, 66 articles were included. The majority of studies were single-center ( n = 52, 78.8%) and observational ( n = 58, 87.9%) in nature. The most commonly reported curriculum components include didactic teaching ( n = 48, 72.7%), dry laboratory skills ( n = 46, 69.7%), and virtual reality (VR) simulation ( n = 44, 66.7%). Curriculum assessment methods varied, including direct observation ( n = 44, 66.7%), video assessment ( n = 26, 39.4%), and self-assessment (6.1%). Objective outcome measures were used in 44 studies (66.7%). None of the studies were fully evaluated according to Kirkpatrick's model, and five studies (7.6%) were fully evaluated according to Messick's framework. The studies were generally found to have moderate methodological quality with a median MERSQI of 11. CONCLUSIONS:Essential components in robotic training curricula identified were didactic teaching, dry laboratory skills, and VR simulation. However, variability in assessment methods used and notable gaps in curricula validation remain evident. This highlights the need for standardized evidence-based development, evaluation, and reporting of robotic curricula to ensure the effective and safe adoption of robotic surgical systems.

BACKGROUND:There has been a recent rapid growth in the adoption of robotic systems across Europe. This study aimed to capture the current state of robotic training in gastrointestinal (GI) surgery and to identify potential challenges and barriers to training within Europe. METHODS:A pan-European survey was designed to account for the opinion of the following GI surgery groups: (i) experts/independent practitioners; (ii) trainees with robotic access; (iii) trainees without robotic access; (iv) robotic industry representatives. The survey explored various aspects, including stakeholder opinions on bedside assisting, console operations, challenges faced and performance assessment. It was distributed through multiple European surgical societies and industry, in addition to social media and snowball sampling, between December 2023 and March 2024. RESULTS:A total of 1360 participants responded, with valid/complete responses from 1045 participants across 38 European countries. Six hundred and ninety-five (68.0%) experts and trainees were not aware of a dedicated robotic training curriculum for trainees, with 13/23 (56.5%) industry representatives not incorporating training for trainees in their programme. Among trainees with access to robotic systems, 94/195 (48.2%) had not performed any robotic cases, citing challenges including a lack of certified robotic trainers and training lists. Both experts and trainees agreed that trainees should start bedside assisting and operating on the console earlier than they currently do. Assessment tools of trainee performance were not being used by 139/479 (29.0%) participants. CONCLUSION:This pan-European survey highlights the need for a standardised robotic curriculum to address the gap in visceral training, assessment and certification. A greater emphasis may be required on implementing robotic training earlier through simulation training, dual console learning, bedside assisting, key clinical performance indicators, and assessment tools. The findings will guide the development of a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery.

AIM/OBJECTIVE:The clinical burden of pelvic exenteration (PE) for locally advanced rectal cancer (LARC) is nationally under-reported. The widespread use of pelvic MRI since 2005 has increased the accuracy of local staging and awareness of the need for 'beyond TME (total mesorectal excision)' surgery. The aim of this study was to assess the volume of patients undergoing PE within England, which factors affected survival outcomes and whether the use of MRI has influenced these outcomes. METHOD/METHODS:The volume of patients undergoing PE and associated survival outcomes across England between 1995 and 2016 was evaluated from Public Health England Hospital Episode Statistics data. RESULTS:A total of 2996 patients were recorded as undergoing PE. The 5-year overall survival rate improved after 2005 compared with prior to 2005 (61.7% vs. 37%, p < 0.001), with no significant difference between cancer registries throughout England. After 2005, the volume of patients undergoing PE and undergoing preoperative MRI increased, as did the number of non-T4 cancers operated on. After 2005, age, preoperative MRI and preoperative radiotherapy were the significant factors influencing 5-year overall survival on multivariate analysis. CONCLUSION/CONCLUSIONS:This review of national data confirms that PE outcomes are under-reported. MRI staging aids with the identification of patients suitable for perioperative treatment, surgery or palliation and facilitates treatment planning. Since 2005, MRI, likely in combination with advances in surgery and perioperative treatment, has improved survival outcomes. It is imperative that detailed information from patients with LARC undergoing PE is captured and reported in order to optimize care and future service provision.

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30 days. There was one conversion to open and one death within 60 days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery.