European Hernia Society RD classification

European Hernia Society guidelines on management of rectus diastasis

Eight surgeons came together to review the available evidence on the management of rectus diastasis and produce evidence-based guidelines. Sadly the evidence quality ranged from very low to moderate. Despite this, the team were able to provide nine recommendations, with the strength of the recommendation ranging from weak to strong.

The nine key questions were:

KQ1 What is the definition of RD?

KQ2 Which modalities are most suitable for diagnosis and assessment of RD?

KQ3 What are the classification systems for RD?

KQ4 What symptoms are associated with RD?

KQ5 Which outcome measures should be used to evaluate treatment for RD?

KQ6 Are there non-operative treatment options for RD?

KQ7 What are the surgical treatment options in patients without concomitant hernias?

KQ8 What is the optimal treatment of rectus diastasis with concomitant umbilical or epigastric hernias?

KQ9 Is there a role for specific postoperative management of RD repair?

This is clearly an area of surgery where higher-quality research is needed; until that is achieved, these guidelines, together with detailed, honest, and open discussions with patients, offer the best pathway towards shared, evidence-based, decision making.

Calculator

Guest blog: “Are you a gambler or an accountant?”

Permanent stoma rates after anterior resection for rectal cancer

Authors: E Back, J Häggström, K Holmgren, M M Haapamäki, P Matthiessen, J Rutegård, M Rutegård

Anterior resection for rectal cancer is a beautiful operation. Whether with hand-held electrocautery or robotic scissors, uncovering the mesorectal package in embryological planes is a most satisfying moment, especially when followed up by a nice, tension-free and well-perfused anastomosis; when all goes well, of course. Unfortunately, anastomotic breakdown is a far too common and dangerous event, tripling the risk of early death1. Quite often, such an event also leads to reoperation and a permanent stoma2. No wonder then that, after decades of research on the merits of defunctioning stomas preventing anastomotic leakage3, there’s a near ubiquitous use in low anterior resection4 (though recent reports challenge this dogma5). The caveat, it seems, is that even temporary stomas cause problems6 and might never be reversed7, questioning the sphincter-saving procedure itself. Moreover, the spectre of severe low anterior resection syndrome rears its ugly head even when a textbook outcome is accomplished8; on the other hand, quality of life might be worse for patients with a permanent stoma9, and this was reported even in the stoma-friendly Scandinavian environment.

The problem is insurmountable, it seems. Do you choose bowel dysfunction and the risk of a leak, or do you opt for a permanent stoma at the get go? Would you dare omit the defunctioning stoma? In short, are you a gambler or an accountant?

In any case, information on an individual patient level is sorely needed for such an important discussion. We’ve recently published a prediction study using pre-operative variables collected from the Swedish Colorectal Cancer Registry, where an attempt has been made at forecasting the risk of a permanent stoma at two years after anterior resection for rectal cancer. While close to five thousand patients contributed data in the analysis, using the ensemble method SuperLearner to develop and validate a moderately accurate prediction model, the real thrust from this study lies in the on-line calculator. The input is shown in Figure 1, where the key predictors can be varied to reflect the patient at hand.

Figure 1. Variables included in the logistic forward-backward selection model can be varied, reflecting the individual patient.

There are certainly more variables of importance out there, and the experienced surgeon will surely add some data to a mental recalculation; smoking, on-going inflammation, continuous immunosuppressive medication, as well as a weak sphincter might decrease the chances of a stoma-free outcome even more. The output can be seen in Figure 2, where the risk of a permanent stoma is depicted in a cross-tabulation of defunctioning stoma use and laparoscopy use; those factors are the only ones that can be altered at a preoperative consultation. Importantly, the output is a predicted risk with measures of uncertainty, providing lower and upper bounds of the permanent stoma risk. Consistently, there is a higher risk of a permanent stoma with the use of a defunctioning stoma, which recently was shown using mediation analysis4.

Figure 2. Output from the prediction model with corresponding measures of uncertainty.

We urge all fellow surgeons to play around with the calculator – it’s actually quite addictive. Perhaps it can be informative in a patient-centred approach to anterior resection, as it seems that, stoma avoidance has the same priority as cure of cancer in some patient populations10. While at it, we can also recommend the internationally validated prediction model for low anterior resection syndrome, POLARS11. While all these prediction models can be improved, it is certainly worthwhile for both surgeon and patient to have some idea of the expected results after anterior resection. 

References

1 Boström P, Haapamäki MM, Rutegård J, Matthiessen P, Rutegård M. Population-based cohort study of the impact on postoperative mortality of anastomotic leakage after anterior resection for rectal cancer. BJS Open. 2019 Feb; 3: 106–111. 

2 Holmgren K, Kverneng Hultberg D, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study. Colorectal Dis. 2017 Dec; 19: 1067–1075. 

3 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007 Aug; 246: 207–214. 

4 Holmgren K, Häggström J, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer. Colorectal Dis. 2021 Jul 26; 

5 Talboom K, Vogel I, Blok RD, Roodbeen SX, Ponsioen CY, Bemelman WA, et al. Highly selective diversion with proactive leakage management after low anterior resection for rectal cancer. Br J Surg. 2021 Jun 22; 108: 609–612.

6 Gessler B, Haglind E, Angenete E. A temporary loop ileostomy affects renal function. Int J Colorectal Dis. 2014 Sep; 29: 1131–1135. 

7 Jørgensen JB, Erichsen R, Pedersen BG, Laurberg S, Iversen LH. Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study. BJS Open. 2020 Dec 2; 4: 1162–1171. 

8 Emmertsen KJ, Laurberg S, Rectal Cancer Function Study Group. Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer. Br J Surg. 2013 Sep; 100: 1377–1387. 

9 Näsvall P, Dahlstrand U, Löwenmark T, Rutegård J, Gunnarsson U, Strigård K. Quality of life in patients with a permanent stoma after rectal cancer surgery. Qual Life Res. 2017 Jan; 26: 55–64. 

10        Wrenn SM, Cepeda-Benito A, Ramos-Valadez DI, Cataldo PA. Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want? Dis Colon Rectum. 2018 Aug; 61: 971–978. 

11        Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, et al. Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut. 2018 Apr; 67: 688–696. 

Guest blog: Keyhole versus open surgery for oesophageal cancer

Authors: B. P. Müller-Stich, P. Probst, H. Nienhüser, S. Fazeli, J. Senft, E. Kalkum, P. Heger, R. Warschkow, F. Nickel, A.T. Billeter, P. P. Grimminger, C. Gutschow, T. S. Dabakuyo-Yonli, G. Piessen, M. Paireder, S. F. Schoppmann, D. L. van der Peet, M. A. Cuesta, P. van der Sluis, R. van Hillegersberg, A. H. Hölscher, M. K. Diener, T. Schmidt

Minimally invasive resection of esophageal cancer might be less traumatic than open resection and has the potential to reduce complications and even improve survival. In contrast, oncological radicality might be negatively affected by the minimal-invasive approach. The aim of this BJS study was to generate 1A level of evidence on the question whether a minimally invasive approach for oncological esophagectomy is advantageous. A systematic literature search was performed and exclusively randomized-controlled trials (RCTs) comparing minimally invasive to open oncological esophagectomy were included in a meta-analysis.

Among 3219 articles six RCTs (four trials from Europe, two from Asia) were found including 822 patients. Survival data and short-term postoperative outcome data was analyzed. From the four European trials (Biere et al. Lancet 2012; Paireder et al. Eur Surg 2018; van der Sluis et al. Ann Surg 2019; Mariette et al. NEJM 2019) individual patient data was retrieved to analyze survival according to the different surgical approaches. Overall survival (56% minimally invasive) vs. (52% open) and disease-free survival (54% vs. 50%) after three years were comparable. Strikingly, the risk of postoperative complications was significantly reduced to one third in the minimal invasive group mainly due to the reduction of pulmonary complications and, in particular, pneumonia. Other parameters, especially those indicating oncological quality of the resection as number of harvested lymph nodes, did not differ between the two groups while the operation time was shorter in the open group. There was no significant difference in the rate of anastomotic leakage, length of stay in the intensive care unit or in the hospital and in the perioperative mortality while total blood loss was lower in the minimal invasive group.

As this meta-analysis included only high-quality randomized controlled trials, it generates high level evidence for the perioperative advantages of minimal invasive esophagectomy. The minimally invasive approach significantly reduces the risk of complications compared to open surgery and does not impair long-term oncological outcome. It should therefore be the preferred approach for cancer-related oesophagectomy. 

Guest blog: Emergency surgery in patients with COVID-19

J Osorio, Z Madrazo, S Videla, B Sainz, A Rodríguez-González, A Campos, M Santamaría, A Pelegrina, C González-Serrano, A Aldeano, A Sarriugarte, C J Gómez-Díaz, D Ruiz-Luna, A García-Ruiz-de-Gordejuela, C Gómez-Gavara, M Gil-Barrionuevo, M Vila, A Clavell, B Campillo, L Millán, C Olona, S Sánchez-Cordero, R Medrano, C A López-Arévalo, N Pérez-Romero, E Artigau, M Calle, V Echenagusia, A Otero, C Tebe, N Pallares, S Biondo, COVID-CIR Collaborative Group Members of the COVID-CIR Collaborative Group

Emergency surgeons may find ourselves attending patients who are potential candidates for emergency surgery and have a COVID-19 infection, with or without evident symptoms. What should we do with these patients? 

The purely descriptive studies published to date show that these patients have a much higher than usual postoperative mortality. Considering these results, avoidance or postponement of surgery has been advised in COVID-positive patients.

However, postponing an emergency surgery may also have its risks. In each individual case, the risk of operating must be weighed against the risk of a non-surgical treatment. Therefore, it is very important to fully understand how and to what extent COVID-19 infection increases postoperative mortality.

Or in other words, is the high mortality observed in COVID-positive patients undergoing surgery entirely due to COVID-19 infection?

If we look closely at these descriptive non comparative studies, most of the COVID-positive patients were older than usual, with many underlying pathologies, and in poor general condition at the time of surgery. Could these factors, rather than the COVID-19 infection itself, explain their bad postoperative outcomes?

Additionally: During the lockdown, patients might have had fear or difficulty of going to the hospital and might therefore be diagnosed in a more advanced stage of their surgical pathologies. Moreover, the collapse of the pandemic could also cause hospitals to have difficulties in rescuing patients with postoperative complications.

If we can measure the true impact of these 3 factors involved (the patient’s context, the lockdown effect and the effect of hospital collapse) we will be able to assess how COVID-19 infection increases the mortality of patients undergoing emergency surgery. And that will allow us to make decisions based on evidence about whether, in each specific case, it is more reasonable to operate or to try not to do so.

The COVIDCIR project was born with the objective of answering that question. From the Bellvitge University Hospital, in Barcelona, we led a registry with 25 participating Spanish hospitals including all emergency general and gastrointestinal surgeries performed during the first wave of the pandemic (from March to June 2020) and during the same period of 2019 . More than 5,000 patients were included.

To assess the impact of COVID infection, we compared COVID-positive patients with COVID-negative patients operated on during the pandemic. This comparison was made using a statistical method called propensity-score matching, which consists of matching COVID-positive patients with COVID-negative controls of similar age, underlying pathologies and general condition at the time of surgery, thus achieving two comparable groups.

We observed that the mortality of these two matched comparable groups was not statistically different. Or, put another way, that the high mortality observed in COVID-infected patients undergoing surgery is more due to their age, underlying pathology and preoperative condition than to a hypothetical COVID risk-multiplier effect.

Thus, the fact that a patient is COVID-positive should not be seen as an absolute impediment to perform an emergency surgery. In each individual patient, the assessment of the risk of performing or postponing surgery should be based, as has always been done, on her or his individual anesthetic risk and its state at the time of diagnosis.

Second, to understand the effect of lockdown, to see if patients were diagnosed too late due to fear or difficulty in accessing, we compared surgical pathologies of COVID-negative patients operated on during the pandemic with those operated during the previous year. We saw that in the pandemic, patients did not present with more advanced peritonitis and that the inflammatory parameters of their laboratory tests were not higher. Thus, the increased mortality observed during the pandemic cannot be attributed to the effect of lockdown.

And finally, to understand the consequences of hospital collapse, we assessed what is called Failure to Rescue of patients: that is, what percentage of patients who present postoperative complications could not be rescued and died as a consequence of the complication. We compared Failure-to-Rescue of COVID-negative patients operated during the pandemic with those operated before the pandemic. Also on this occasion we carried out the propensity-score matching comparison, matching patients from both groups from the same hospital and of similar age, underlying pathologies and severity of surgical pathology.

We found that COVID-negative patients operated on during the COVID-19-pandemic had the same risk of postoperative complications, but a greater Failure-to-Rescue than before. This fact was evident in the 25 participating hospitals and is probably explained by the hospital collapse in the pandemic context.  

Increased level of fluorescence intensity of breast cancer and normal mammary gland tissue a Haematoxylin and eosin-stained sections of normal and cancer tissue. The area outlined in green indicates the breast cancer. b Top images are fluorescence intensity images of γ-glutamyl hydroxymethyl rhodamine green (gGlu-HMRG) (green) at each time point overlaid on white light images. The fluorescence increase (FI) was obtained by subtracting the baseline fluorescence from the fluorescence at each time point. FIs are represented by the pseudocolour scale on the right side of the image.

Guest blog: a novel fluorescence technique for detecting breast cancer

Author: Hiroki Ueo, Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Ueo Breast Cancer Hospital, Oita, Japan

Breast cancer is the most common cancer in women, and its incidence continues to increase worldwide. From the patient’s perspective, breast conserving surgery (BCS) with radiation achieves a balance between a satisfactory cosmetic result and a low recurrence rate. Although it has been established as a routine surgery, surgeons need to be careful about positive surgical margins. Remnant cancer cells in the preserved tissue increase the risk of recurrence. Therefore, a positive margin on postoperative pathology warrants additional surgery. In these cases, the additional treatment harbours unexpected outcomes, including physical, mental, cosmetic, and economic burden on the patients. 

To avoid the additional operation, pathological evaluation using an intraoperative frozen section is conducted. It is the most reliable method to prevent misdiagnosis and to achieve clear surgical margins. However, this conventional method is time consuming and costly. Moreover, it is dependent on the skill and experience of the pathologists and personnel, and it requires space for preparation of the frozen sections. Therefore, only a limited number of samples are examined to save time and resources. An alternative, rapid, and reliable technique to detect cancer in surgical margins enables simultaneous testing, leading to a reduced false negative rate of local recurrence incidence. In addition, pathologists can focus on the definitive diagnosis using permanent paraffin sections because it is difficult to make a diagnosis based on intraoperative frozen sections without pathological architecture. Pathologists only need to make an intraoperative diagnosis when the specimen cannot be evaluated via the fluorescence procedure. Thus, it is important to enhance the rapid fluorescent detection of breast cancer during surgery. To address these diagnostic issues, Prof. Urano invented chemical reagents (gamma-glutamyl hydroxymethyl rhodamine green [gGlu-HMRG]) that quickly fluoresce by reacting with an enzyme (gamma-glutamyl transferase [GGT]), overexpressed in cancerous tissues. It exhibits strong fluorescence a few minutes after reacting with GGT in vitro. A gGlu-HMRG solution is applied to the surgical margins to recognize cancer cells as green fluorescence intraoperatively. A previous study in 2015 documented the ability of this reagent to mark cancerous tissues in surgical breast tissues. Furthermore, this reagent did not interfere with the pathological examination, while the frozen section analysis tissues were difficult to reuse as formalin-fixed and paraffin-embedded permanent pathological specimens. 

The clinical utility of this technique was examined. The results were published in the British Journal of Surgery. Since the initial report in 2015, a more feasible and reproducible sample preparation protocol has been developed. Then, a dedicated apparatus, including a built-in camera, software program, and multiple sample wells, was developed. This system automatically measured and analyzed the increase in fluorescence of multiple samples simultaneously. Then, the increase in fluorescence of gGlu-HMRG, applied to breast tissues, was measured in four different institutes. The sample tissues were examined by four pathologists independently. These pathologists diagnosed the samples without knowing the background information of the patients. The clinical utility of the current fluorescent procedure was evaluated by comparing the fluorescence data and the pathological diagnosis. 

A clear threshold to distinguish between cancerous and non-cancerous tissues was not determined due to the heterogeneity of breast cancer tissues. Instead, the negative threshold to achieve a false negative rate <2% and the positive threshold to achieve a false positive rate <2% were established. Samples in which the increase in fluorescence was below the negative threshold value were considered cancer-free margins with a false negative rate <2%. The false negative samples in our study were tissues containing non-invasive cancer. This suggested that the samples below the negative threshold can be considered free of invasive cancer. Samples in which the increase in fluorescence was above the positive threshold value were considered cancerous tissue with a false positive rate <2%.

The disease prevalence determines the performance of a diagnostic tool. The percentage of positive and negative test results among those with or without the disease are the positive and negative predictive values, respectively. These positive and negative predictive values depended on the prevalence. Therefore, to estimate the performance of this technique, the prevalence and margin positive rate in this case should be considered. The margin positive rate was expectedly lower than that of our clinical study. In our protocol, three pieces of tissue were sampled: the central portion, where the breast cancer is located; its periphery, which contains non-invasive cancer; and the distal portion, which ideally contains normal mammary tissue. Cancer was detected in 46% of the samples. Based on the actual margin assessment, the prevalence was lower than that of our study. Assuming a prevalence <30%, the negative predictive value, the ratio of true negative samples among fluorescent negative samples, was larger than 98%. This indicated that this method was useful for detecting negative margins. 

According to this multicenter study, the fluorescent diagnosis was applicable to any breast cancer subtype, regardless of its pathological findings and subtype. Moreover, the similar accuracy among several institutes confirmed that the fluorescent diagnosis was applicable to any institute, following the protocol. Compared to the intraoperative frozen section analysis, the fluorescent diagnosis was a more rapid and accessible method with a low cost. It was not dependent on the skills of pathologists, and it did not require a large amount of space.           

In conclusion, this method can facilitate the rapid assessment of negative surgical margins during BCS while reducing the testing time, cost of diagnosis, and tasks of the pathologists and staff. 

Roux en Y gastric bypass

Guest blog: Bariatric Surgery – the safe solution to the metabolic pandemic

Authors: A G N Robertson (Twitter: @robertson_a), T Wiggins (@TomWiggins23), F P Robertson, L Huppler (@LucyLucyHuppler), B Doleman, E M Harrison (@ewenharrison), M Hollyman (@misshollyman), R Welbourn

Obesity is the preventable and reversible disease of our lifetime. It is a worldwide health, economic and environmental problem in need of urgent and essential attention, and it has become clear that the world needs more than the traditional recommendations to survive this metabolic pandemic.  The traditional advice has been acknowledged for centuries and even more so since the worldwide prevalence of obesity nearly tripled between 1975 and 20161. These lifestyle recommendations include physical exercise, less high calorific food content, balanced meals, optimising portion size, intermittent fasting and so on; we all know them. However, the human race is still falling short of tackling the major public health concern that this disease threatens to be. 

Bariatric or weight loss surgery is a surgical sub-speciality which has been evolving since the first procedures of this type in the mid 20th century. Its development has led to the most effective method to achieve long-term weight loss, as well as the additional health benefits weight loss offers as a by-product. However, accessibility to this specialist treatment is limited with only 1% of eligible patients going on to receive bariatric surgery.2Reasons for this limited access are multifactorial, however a considerable factor is thought to be concerns regarding the perceived risks of weight-loss surgery from patients across all populations. We should therefore aim to give our patients the most up to date worldwide risk of mortality of these potentially life-saving procedures. 

This month in the BJS, we’ve published the largest meta-analysis asking this question to date – and the findings are pivotal at providing a unanimous international statistic on this discussion. We’ve looked at perioperative mortality rates (inpatient, 30 day and 90 day mortality) of a range of bariatric procedures to include laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), Laparoscopic Roux-en-Y gastric bypass (LRYGB), one-anastomosis gastric bypass (OAGB), biliopancreatic diversion/duodenal switch (BPD-DS) and other malabsorptive procedures. We’ve included 58 studies in our meta-analysis which has given us information on roughly 3.6 million patients over a 6-year period from worldwide practice. Multiple sources for data were used including administrative datasets, bariatric surgery registries, large scale case series as well as randomised controlled trials (RCTs). 

The paper looks at mortality within each subgroup of operation. There are interesting findings within this showing significant differences in perioperative mortality between procedures (P<0.001) with biliopancreatic diversion/duodenal switch or other malabsorptive procedures having the highest perioperative mortality rates (0.41%) and laparoscopic adjustable gastric band (LAGB) followed by sleeve gastrectomy (SG) being the procedures with the lowest perioperative mortality rates (0.03% and 0.05% respectively). This naturally reflects the trend towards these latter procedures being offered more commonly in international practice. Although this paper looks closely at perioperative mortality it is noteworthy to mention that it doesn’t look at long term morbidity following these procedures or their potential complication rates. 

Without a doubt, our most noteworthy finding has been the discovery that overall perioperative mortality following bariatric surgery is likely much lower than previously thought, with our pooled perioperative mortality rate at 0.08% (95% CI 0.06%-0.10%). It perhaps makes this statistic even more relatable when this is compared to other procedures we consider as ‘low-risk’ in our daily surgical practice. For example, laparoscopic cholecystectomy or fundoplication have comparable perioperative mortality rates reported at 0.1%. This new statistic is also lower than previously quoted in the literature from smaller scale studies. The mortality rate calculated in this meta-analysis puts bariatric surgery as a whole at lower risk of mortality as knee arthroplasty (0.3%)3. With this in mind, we hope that there can be a culture shift from avoidance of bariatric surgery due to risk, to giving patients the correct information to confidently weigh up the true risks and benefits of these procedures when indicated. 

How should these findings shape the future of bariatric surgery in Europe and beyond? Certainly in the UK, the acceptability of bariatric surgery as a viable treatment option for obesity is limited. It is surprising how often we see patients who are eligible for bariatric surgery and who have met the criteria for some time yet to be offered this as a treatment option. There is a distinct barrier to accessing bariatric surgery for the wider population, perhaps due to taboo surrounding broaching the issue of weight in the primary care setting, and although many general practitioners do this very well, there remain limiting factors. Another stand-out factor includes lack of funding or commissioning within the public health service for referral for weight loss specialist services. Therefore, with the addition of this new internationally applicable statistic, our hope is that the most effective treatment option for sustained weight loss can now be available for all that require it. Bariatric surgery is safe. 

  1. https://www.worldobesity.org/about/about-obesity/prevalence-of-obesity
  2. Welbourn R, le Roux CW, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery; how much should we do? Bmj. 2016;353:i1472.
  3. Aminian A, Brethauer SA, Kirwan JP, Kashyap SR, Burguera B, Schauer PR. How safe is metabolic/diabetes surgery? Diabetes, Obes Metab. 2015; 17(2):198-201.

Image source: Eslam ibrahim66 2021 Creative Commons

Visual abstract for COVIDHAREM appendicitis study

Guest blog: Antibiotics – not operations – to treat adult appendicitis?

By Hannah Javanmard-Emamghissi (@hannahjavanmard), NELA Research Fellow and RCSEng Research fellow on behalf of the COVID:HAREM Collaborative 

Keyhole surgery (laparoscopic appendicectomy) has been the mainstay of adult appendicitis treatment in Europe and the United States for the last several decades. In spite of this numerous trials have been ongoing exploring if there is a role for non-operative management of appendicitis with antibiotics. The APPAC and CODA trials both demonstrated that antibiotics were effective at treating simple appendicitis that was not perforated, gangrenous or associated with an abscess in the majority of patients.(1,2) However, it remained an underutilised treatment strategy. 

This all changed during February and March of 2020, when the Sars-COV-2 virus (COVID-29) swept across much of the globe. Healthcare providers were forced to make contingency plans for hospitals that faced being overwhelmed by patients infected with COVID-19. Much of the anaesthetic workforce had been redeployed to intensive cares and there was uncertainty of the safety of general anaesthesia for patients with peri-operative COVID-19 and of the safety of the theatre teams exposed to virus aerosols during laparoscopy.(3,4) Non-operative management strategies were implemented recommended by surgical professional bodies across many surgical disciplines as a way of mitigating for these uncertainties.(5)

Our collaborative’s report, just published in BJS, represents the first time non-operative management of appendicitis has been implemented on a wide scale in the United Kingdom. We collected data on patients over the age of 18 presenting during the first wave of the COVID-19 pandemic presented with signs and symptoms suggestive of acute appendicitis, whether they were managed operatively and non-operatively. These patients were followed up for 90 days for length of hospital stay, complications, representation to hospital and appendicitis recurrence. Patients managed non-operatively were matched with similar patients managed operatively using propensity score matching, and their outcomes were compared.

Patients from 97 hospitals across the United Kingdom and Republic of Ireland were included in our study. Three thousand four hundred and twenty patients were included, of which 41% had initially been treated with antibiotics. When they were matched using propensity score matching with similar patients who had non-operative management, the group treated with antibiotics spent less time in hospital and had fewer complications than those who had an operative management. Non-operative management was successful in 80% of the patients managed in this way, with 20% going on to have an appendicectomy in the 90 days after their first attendance. 

We also teamed up with a health economics team from the London School of Tropical Medicine to calculate the costs associated with each treatment method. We found that, even when accounting for the 20% of patients that had surgery within the 3 months of being treated with antibiotics, non-operative management was associated with a cost reduction of €1034 per patient compared to operative management. 

This study proves that antibiotics are an effective management strategy for appendicitis and can be utilised on a large scale beyond trials for the first time ever. Patients may be keen to avoid surgery for a number of reasons and going forward surgeons should incorporate a discussion about the risks, benefits and uncertainties of non-operative management into conversations they have with patients about appendicitis management options. Our results have shown how reducing the number of operations we do for appendicitis can have benefits for the patient in terms of complications and days in the hospital away from work and home, but it may have wider benefits to the hospital and world. Not only is non-operative management cheaper for the hospital, but reducing the number of appendicectomies performed can free up theatre time so the most urgent surgical emergencies have less delay accessing theatre. All operations are associated with a significant amount of carbon emissions and single use plastic waste, but despite our best efforts to reduce the harm that surgery can cause to the environment the most effective strategy remains reducing the amount of unnecessary surgery performed.(6)

That is not to say that the study of non-operative management of appendicitis is over, there is still debate about the long-term efficacy of antibiotic management and concern that some cancers of the appendix may be missed by not removing the appendix at the first presentation, as well as questions about how acceptable patients find non-operative management. Our collaborative hopes to answer these questions and more in a one year follow up study and ongoing patient and public involvement work. 

Conflicts of Interest 

None to declare 

Funding

No funding was received for this blog article 

References

1.        Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259–1265. 

2.        CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NL, Odom SR, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Nov 12;383(20):1907-1919.

3.        Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet [Internet]. 2020 Jul 4 [cited 2020 Nov 5];396(10243):27–38. Available from: https://doi.org/10.1016/

4.        SH E. Should we continue using laparoscopy amid the COVID-19 pandemic? Br J Surg [Internet]. 2020 Jul 1 [cited 2021 Sep 5];107(8):e240–1. Available from: https://pubmed.ncbi.nlm.nih.gov/32432344/

5.        Hettiaratchy S, Deakin D. Guidance for surgeons working during the COVID-19 pandemic from the Surgical Royal Colleges of the United Kingdom and Ireland. Intercollegaite Royal Colleges of Surgery. London; 2020. 

6.        MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planetary Health [Internet]. 2017 Dec 1 [cited 2021 Sep 5];1(9):e381–8. Available from: http://www.thelancet.com/article/S2542519617301626/fulltext

External aspect of the operative field: DaVinci™ robotic system docked to the patient

Guest blog: What advantage does robot-assisted and transanal TME have over laparoscopy?

Authors: Jeroen C. Hol, Colin Sietses

Contact: j.c.hol@amsterdamumc.nl

Correspondence to: “Comparison of laparoscopic versus robot-assisted versus TaTME surgery for rectal cancer: a retrospective propensity score matched cohort study of short-term outcomes

Image source: Robinson Poffo et. al. Robotic surgery in Cardiology: a safe and effective procedure. https://creativecommons.org/licenses/by/4.0/ under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The emergence of minimally invasive surgery has led to the development of three new surgical techniques for oncological rectal resections: laparoscopic, robot-assisted and transanal TME (TaTME). When we compared the three techniques executed in expert centres, we expected to find an advantage for one of the three techniques in terms of reduced complication rates. But contrary to our expectations, no difference was seen. There was one striking difference however, when comparing these techniques, though it might be something different than you might have thought. We shine a light on all three techniques to explain their advantages. 

Laparoscopy: minimally invasive surgery

In the 1980’s, Heald introduced the total mesorectal excision (TME) principle, which comprises excision of the rectum and its surrounding fatty envelop with preservation of the autonomic nerves [1]. TME has become the golden standard for surgical resection for rectal cancer and helped dropping local recurrence rates drastically. The past decades laparoscopy has been introduced and gradually replaced open surgery. Laparoscopy offers short term benefits of minimally invasive surgery, such as faster recovery and reduced complication rates [2, 3]. It offers similar long-term outcome as open surgery [4]. But laparoscopy is technically demanding because it is difficult to work with rigid instruments in the narrow and confined area of the pelvis. Therefore, conversion rates to open surgery of more than 10% were seen [5]. Conversion is linked to increased morbidity and worse oncological outcome [6]. In order to overcome those technical limitations of laparoscopic TME, new techniques have been introduced; robot-assisted TME and TaTME. 

Robot-assisted TME: the same, but different

Robot-assisted TME comprises the same approach as laparoscopy, but with the use of a surgical robot. The surgical robot provides a stable platform with supreme vision and supreme instrument handling. Surgeons thought this technique might improve results in terms of reduced complication rates and reduced conversion rates. However, the largest randomized trial so far comparing robot-assisted and laparoscopic TME failed to show any difference in these outcomes [7]. This might have been the result of a methodological flaw, because the robotic surgeons in that trial were not as experienced as their laparoscopic colleagues [8]. In our study, we tried to eliminate this by only selecting experienced centres that were beyond their learning curve. However, we did not see reduced complication rates or reduced conversion rates after robot-assisted TME compared to laparoscopy.

Transanal TME: a different approach

TaTME comprises a different approach to address the most difficult part of the dissection. In TaTME the most distal and difficult part of the rectum is dissected from below using a transanal insufflator port. However, this is a technically demanding technique and has a long learning curve [9]. Some initial series showed high loco regional recurrence rates, which even led to a halt of TaTME in Norway [10, 11]. The potential learning curve effect is now part of an ongoing debate about the oncological safety of this technique. Most initial results however looked promising and showed consistently good quality specimen and lower conversion rates [12, 13]. In our study, conversion rates, number of complete specimen and morbidity rates did not differ from the other laparoscopy and robot-assisted TME. 

Technological advantage 

The results of our study showed similar and acceptable short-term results for all three techniques in expert centres. The most striking difference was that in centres with robot-assisted or TaTME, more primary anastomoses were made. The technological advantage of the two new techniques could have contributed to higher restorative rates. Both robot-assisted and TaTME provide better access and visibility to the distal rectum, enabling surgeons to complete the TME dissection safely and create an anastomosis. Robot-assisted TME could overcome technical limitations of laparoscopy in the narrow pelvis thanks to the use of 3D vision, lack of tremor, and superior instrument handling, thereby facilitating safe creation of an anastomosis [7, 14]. TaTME does not need multiple staple firing to transect the distal rectum and without requiring conversion to open surgery [13]. In fact, TaTME does not need cross-stapling at all, preventing the creation of dog-ears which are prone to ischemia [15]. 

Patient’s perspective

In conclusion, the technological advantage of robot-assisted TME and TaTME manifests itself in higher restorative rates. Each technique seems to be equally beneficial in terms of oncological outcomes and morbidity. However, anastomosis creation, quality of life and functional outcome are becoming of great importance to patients. It seems to be that an increasing proportion of patients is now in pursue of an anastomosis. The overall anastomosis rate of more than 84% for robot-assisted and TaTME in our study was higher than the anastomosis rate of 50% in a previous national study [16]. A note of caution should be added, as an anastomosis might not be always better in terms of functional outcome and quality of life. Patients with a low anastomosis are at risk of developing severe low anterior resection syndrome (LARS) symptoms. Severe LARS symptoms can have a detrimental effect on quality of life [17].  Further research should be undertaken to investigate whether a higher anastomosis rate is beneficial in terms of quality of life and functional outcome and whether this higher anastomosis rate actually leads to increased patient satisfaction. 

References

1.         Heald, R.J., E.M. Husband, and R.D. Ryall, The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg, 1982. 69(10): p. 613-6.

2.         Stevenson, A.R., et al., Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA, 2015. 314(13): p. 1356-63.

3.         van der Pas, M.H., et al., Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol, 2013. 14(3): p. 210-8.

4.         Bonjer, H.J., et al., A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. N Engl J Med, 2015. 373(2): p. 194.

5.         Chen, K., et al., Laparoscopic versus open surgery for rectal cancer: A meta-analysis of classic randomized controlled trials and high-quality Nonrandomized Studies in the last 5 years. Int J Surg, 2017. 39: p. 1-10.

6.         Allaix, M.E., et al., Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival? World J Gastroenterol, 2016. 22(37): p. 8304-8313.

7.         Jayne, D., et al., Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial. JAMA, 2017. 318(16): p. 1569-1580.

8.         Corrigan, N., et al., Exploring and adjusting for potential learning effects in ROLARR: a randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection. Trials, 2018. 19(1): p. 339.

9.         Koedam, T.W.A., et al., Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve.Tech Coloproctol, 2018. 22(4): p. 279-287.

10.       Larsen, S.G., et al., Norwegian moratorium on transanal total mesorectal excision. Br J Surg, 2019. 106(9): p. 1120-1121.

11.       van Oostendorp, S.E., et al., Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg, 2020.

12.       Detering, R., et al., Three-Year Nationwide Experience with Transanal Total Mesorectal Excision for Rectal Cancer in the Netherlands: A Propensity Score-Matched Comparison with Conventional Laparoscopic Total Mesorectal Excision. J Am Coll Surg, 2019. 228(3): p. 235-244 e1.

13.       Grass, J.K., et al., Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery. Eur J Surg Oncol, 2019. 45(4): p. 498-509.

14.       Kim, M.J., et al., Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial. Ann Surg, 2018. 267(2): p. 243-251.

15.       Penna, M., et al., Four anastomotic techniques following transanal total mesorectal excision (TaTME). Tech Coloproctol, 2016. 20(3): p. 185-91.

16.       Borstlap, W.A.A., et al., Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study. Ann Surg, 2017. 266(5): p. 870-877.

17.       Emmertsen, K.J. and S. Laurberg, Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg, 2012. 255(5): p. 922-8.

Schematic of process for classifier design

Guest blog: 21st century surgery is digital

Ronan Cahill, Digital Surgery Unit, Mater Misericordiae University Hospital, Dublin, Ireland and UCD Centre for Precision Surgery, Dublin, Ireland.

Niall Hardy, UCD Centre for Precision Surgery, Dublin, Ireland.

Pol MacAonghusa, IBM Research, Dublin, Ireland.

Twitter @matersurgery Email: ronan.cahill@ucd.ie

Cancerous tissue behaves differently from non-cancerous tissue. Every academic oncology paper ever written tells us this. The appearances of any cancer primary (or indeed secondary lesion) result from biological and molecular processes that are the hallmarks of malignancy including dysregulated cell function and composition, host-cancer stromal and inflammatory response and angiogenesis. However, we surgeons haven’t really yet been able to exploit this knowledge during surgery in a way that helps us make a better operation. Instead, our learning and research about oncological cellular processes has predominantly advanced through basic science geared more towards perioperative prognostication and/or adjuvant therapy stratification. Wouldn’t it be great if realisation of cancer microprocesses could usefully inform decision-making intraoperatively?

We’ve just published an initial report in the BJS showing this very thing – that it is indeed possible to ‘see’ cancer by its behaviour in real-time intraoperatively. We’ve used Artificial Intelligence (AI) methods in combination with near-infrared fluorescence laparoendoscopy to judge and classify neoplastic tissue nature through the observation of differential dye diffusion through the region of interest in comparison with that happening in normal tissue being viewed alongside it. Through our understanding of biophysics (flow parameters and light/dye interaction properties), a lot of information can be drawn out over short periods of times via advanced computer vision methodology. With surgical video recording in the region of 30 frames per second, big data generates over the time frame of a few minutes.  While the gross signal shifts are discernible even without AI, smart machine learning capabilities certainly mean their interrogation becomes really usable in the provision of classification data within moments. What’s more, while we’ve focused initially on colorectal cancer, the processes we are exploiting seem common across other solid cancers and using other camera-based imaging systems. By combining with the considerable amount of knowledge we already have accrued regarding tissue biology, chemistry, physics as relate and indeed surgery, our AI methods are giving explainable and more importantly interpretable recommendations with confidence using a smaller dataset than that demanded by deep learning methodologies.

This though is just an early exemplar of what’s becoming possible through ‘Digital Surgery’, a concept that seems far more likely to transform contemporary surgical practice than our current general surgery “robotic” systems, hulking electromechanical tools entirely dependent on the user – a rather 20th century concept! Indeed, there is sophisticated technology everywhere in today’s operating theatres – surgeons sure don’t lack technical capability. Yet often despite vaulting costs, advance of real, value-based outcomes has been disappointingly marginal in comparison over the last two decades. The key bit for evolved surgery is instead going to be assisting surgeons to make the best decision possible for each individual patient by providing useful, discerning information regarding the surgery happening right now, and somehow plugging this case circumstances directly into the broad knowledge bank of expertise we have accrued as a profession (and not just be dependent on any single surgeon’s own experience).

To do this we need to realise the importance of visualisation in surgical procedures versus manual dexterity.  All surgery is performed through the visual interpretation of tissue appearances and proceeds via the perception-action cycle (‘sense, predict, act, adjust’). This is most evident during minimally invasive operations where a camera is used to display internal images on a screen but applies of course to open procedures as well. As all intraoperative decisions are made by the surgeon, the entire purpose of surgical imaging has been to present the best (‘most visually appealing’) picture to the surgeon for this purpose. Experiential surgical training is for the purpose of developing the ‘surgical eye’, that is learning how to make qualitative intraoperative judgments reliably to a reasonable standard. We haven’t however gotten the most out of the computer attached to the camera beyond image processing where we have concerned ourselves with display resolutions and widths. 

Imagine instead if some useful added interpretations of images could be made without adding extra cognitive burden to the surgeon, perhaps with straightforward on-screen prompts to better personalise decisions? This would be particularly exciting if these data were not otherwise easily realisable by human cognition alone and could be immediately and directly relevant to the person undergoing the operation. Every operation is in effect a unique undertaking, informed by probabilities accruing through individual and collected prior experience for sure but a new thing in and of itself for which the outcome at the time of its performance is unknown. How this individual patient differs from others and most especially how might an adverse outcome be avoided is a crucial thing to flag before any irreversible surgical step that commits an inevitable future. 

Right now, we are in a golden age of imaging. This is intricately linked to advances in computer processing and sharing power along with AI methods. This means we can harvest great additional information from the natural world around us across the spectrum of enormous (radio waves spanning the universe) to tiny (high resolution atomic imaging) distances and apply methods to help crystalise what this means to the observer. While a lot of AI is being directed at the easier and safer areas of standard patient cohort datasets, increasingly it’s possible to apply computer intelligence to the data rich surgical video feeds being generated routinely during operations to present insights to the surgeon. While early first steps at the moment relate to rather bread and butter applications such as instrument or lesion recognition and tracking as well as digital subtraction of smoke or anonymization protocols to prevent inadvertent capture of operating rooms teams when the camera is outside the patient, soon the capability to parse, segment and foretell likely best next operative steps will be possible at scale.

At present, the biggest limitation is that surgery lacks large warehoused archives of annotated imagery because operative video is a more complex dataset to scrutinise than the narrower image datasets available in specialities such as radiology, pathology and ophthalmology. Thanks to advances in computing, this is changing. Surgical video aggregation to enable building of representative cohorts is increasingly possible and, by combining with metadata and surgical insights, its full value can begin to be realised. GDPR frameworks provide structure and surgeons are increasingly understanding of the value of collaborating in research, education and practice development. However, while certain siloed sites focused around specific industry projects are already manifesting, the key area for greatest general advance lies within the surgical community combining broadly to construct appropriately developed and secured, curated video banks of procedures that can then be made accessible to entities from regulators and standard bodies, academia and indeed corporations capable of advancing surgery. This gives by far the greatest chance of the best of surgical traditions carrying through the 21st century while our weak spots are fortified for better surgery in the public interest.

Further reading: 
Artificial intelligence indocyanine green (ICG) perfusion for colorectal cancer intra-operative tissue classification.
 Cahill RA, O’Shea DF, Khan MF, Khokhar HA, Epperlein JP, Mac Aonghusa PG, Nair R, Zhuk SM.Br J Surg. 2021 Jan 27;108(1):5-9. https://doi.org/10.1093/bjs/znaa004 PMID: 33640921 

The age of surgical operative video big data – My bicycle or our park? Cahill RA, MacAonghusa P, Mortensen N. The Surgeon 2021 Epub ahead of press https://doi.org/10.1016/j.surge.2021.03.006

Ways of seeing – it’s all in the image. Cahill RA. Colorectal Dis. 2018 Jun;20(6):467-468. https://doi.org/10.1111/codi.14265 PMID: 29864253

tangled threads

Appendicitis (really).

tangled wicker mooring ropes in ship

Sometimes you read a collection of paper and see common threads. Here are some from BJS Open.

Nihil sub sole novum

The phrase ‘nothing new under the sun’ is often a cry of despair borne from monotony. Is this true for appendicitis? From reading this article from 1893, there are certainly principles that remain constant. There has been a recent flurry of papers on appendicitis published in BJS Open. As I’ve been reading them as they hit early access, I thought it might be interesting to have a look at them and see where they fit in the wider context of the literature and practice. 

We enter 2021 with the non-operative management of acute uncomplicated appendicitis being broadly accepted as a viable option. This has likely been increased by the (ongoing) COVID pandemic, with its subsequent impact on surgical resource and workforce availability.

First of all, appendicitis remains relevant. The paediatric surgery research priority setting exercise had two questions on appendicitis; one on the antibiotic only approach in uncomplicated appendicitis, and one on the use of drains post-operatively.

Telling the difference

And then we turn our attention to discriminating between complicated and uncomplicated appendicitis. What is the best modality? As a profession, we are keen not to over irradiate our patients with excessive CT scans. Naturally, we look to ultrasound and MRI scans. Unfortunately, a systematic review of diagnostic accuracy in all three modalities found limitations in both US and MRI, and a high negative predictive value when CT is used. So that is settled then, CT to reassure us that the patient has uncomplicated appendicitis and can be managed non-operatively.

Caution was raised by a study from Helsinki, Finland. This looked at 837 patients diagnosed with uncomplicated appendicitis on CT scan, and found that at surgery, 22% had perforated. The data is from 2014/2015, which isn’t *that* long ago, although it feels higher than I expected. So perhaps we need a better test to pick out complicated appendicitis?

Blood tests

Enter Kiss et al, who looked at genetic expression in peripheral blood mononuclear cells. This study found upregulation of genes associated with T & B cell interaction in those patients who had phlegmonous appendicitis, and upregulation of markers of antibacterial activity (e.g. monocytes and neutrophils). Perhaps this is interesting and personalised blood test to explore for the future. Point of care testing anyone? On the point of novel tests, an Irish group looked at the role of circulating fibrocytes in the diagnosis of appendicitis. This is a class of cells that is increased in states of inflammation. Sensitivity and specificity were in the high 60s, but in a modest sample that might be expected. Something to investigate further in a larger sample for sure. 

And finally, the role of blood tests in the immunosuppressed, specifically the HIV+ve patient. We classically use blood tests such as leucocyte count or C-reactive protein to aid diagnosis. This study from South Africa showed that, perhaps counterintuitively, CRP levels tended to be higher in HIV+ve patients with appendicitis than HIV-ve patients with appendicitis. Leucocyte levels were lower in the HIV+ve group. Useful to know this data exists as many of the risk models used are not calibrated for this population.

Summary

To wrap this up, I want to point out the opening gambit from the paper by Kiss et al:

‘Surgeons know how to treat appendicitis: either surgically with appendicectomy and supporting measures like abscess drainage, or conservatively without operation’

Whilst we may retain the technical principles of surgery, there is work to do. This seems to be around:

  • Improving the diagnosis of appendicitis, hopefully avoiding radiation in the process.
  • Accurate estimation of risk of perforation in patients with a diagnosis of appendicitis

Publications arising in the last six months in BJS Open alone suggest that we have a way to go to truly ‘know‘ how to treat appendicitis.

MJL.