Surgery (St Vincent's) - Research Publications
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ItemNo Preview AvailableImpact of the approach on conversion to open surgery during minimally invasive restorative total mesorectal excision for rectal cancer(SPRINGER, 2023-03-27)BACKGROUND: The aim of this study is to explore the impact of the approach on conversion in patients undergoing minimally invasive restorative total mesorectal excision within a single unit. METHODS: A retrospective cohort study was conducted. Patients with rectal cancer undergoing minimally invasive restorative total mesorectal excision between January 2006 and June 2020 were included. Subjects were classified according to the presence or absence of conversion. Baseline variables and short-term outcomes were compared. Regression analyses were conducted to assess the relationship between the approach and conversion. RESULTS: During the study period, 318 patients underwent a restorative proctectomy. Of these, 240 met the inclusion criteria. Robotic and laparoscopic approaches were undertaken in 147 (61.3%) and 93 (38.8%) cases, respectively. A transanal approach was utilised in 62 (25.8%) cases (58.1% in combination with a robotic transabdominal approach). Conversion to open surgery occurred in 30 cases (12.5%). Conversion was associated with an increased overall complication rate (P = 0.003), surgical complications (P = 0.009), superficial surgical site infections (P = 0.02) and an increased length of hospital stay (P = 0.006). Robotic and transanal approaches were both associated with decreased conversion rates. The multiple logistic regression analysis, however, showed that only a transanal approach was independently associated with a lower risk of conversion (OR 0.147, 0.023-0.532; P = 0.01), whilst obesity was an independent risk factor for conversion (OR 4.388, 1.852-10.56; P < 0.00). CONCLUSIONS: A transanal component is associated with a reduced conversion rate in minimally invasive restorative total mesorectal excision, regardless of the transabdominal approach utilised. Larger studies will be required to confirm these findings and define which subgroup of patients could benefit from transanal component when a robotic approach is undertaken.
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ItemRobotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short-term outcomes(WILEY, 2022-07)AIM: To explore the feasibility and safety of robotic beyond total mesorectal excision (TME) surgery for primary and recurrent pelvic malignancy. METHODS: Patients undergoing robotic beyond TME resections for primary or recurrent pelvic malignancy between July 2015 and July 2021 in a public quaternary and a private tertiary centre were included. Demographic and clinical data were recorded and outcomes analysed. RESULTS: Twenty-four patients (50% males) were included, with a median age of 58 (45-70.8) years, and a BMI of 26 (24.3-28.1) kg/m2 . Indication for surgery was rectal adenocarcinoma in nineteen, leiomyosarcoma in two, anal squamous cell carcinoma in one and combined rectal and prostatic adenocarcinoma in two patients. All patients required resection of at least one adjacent pelvic organ including genitourinary structures (n = 23), internal iliac vessels (n = 3) and/or bone (n = 2). Eleven patients had a restorative procedure. Of the 13 nonrestorative cases, nine needed perineal reconstruction with a flap. There was one conversion due to bleeding. The mean operating time was 370 (285-424) min, and the median blood loss was 400 (200-2,000) ml. The median length of stay was 16 (9.3-23.8) days. Fourteen patients (58.3%) had postoperative complications; eight of them (33.3%) were Clavien-Dindo III or more complication. Twenty-three (95.8%) patients had an R0 resection. During a median follow-up of 10 (7-23.5) months, five patients (20.8%) had systemic recurrences. No local recurrences were identified during the study period. CONCLUSION: Implementation of robotic beyond TME surgery for primary and recurrent pelvic malignancy is feasible within a highly specialised setting.
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ItemWhat are clinically relevant performance metrics in robotic surgery? A systematic review of the literature(SPRINGERNATURE, 2023-04)A crucial element of any surgical training program is the ability to provide procedure-specific, objective, and reliable measures of performance. During robotic surgery, objective clinically relevant performance metrics (CRPMs) can provide tailored contextual feedback and correlate with clinical outcomes. This review aims to define CRPMs, assess their validity in robotic surgical training and compare CRPMs to existing measures of robotic performance. A systematic search of Medline and Embase databases was conducted in May 2022 following the PRISMA guidelines. The search terms included Clinically Relevant Performance Metrics (CRPMs) OR Clinically Relevant Outcome Measures (CROMs) AND robotic surgery. The study settings, speciality, operative context, study design, metric details, and validation status were extracted and analysed. The initial search yielded 116 citations, of which 6 were included. Citation searching identified 3 additional studies, resulting in 9 studies included in this review. Metrics were defined as CRPMs, CROMs, proficiency-based performance metrics and reference-procedure metrics which were developed using a modified Delphi methodology. All metrics underwent both contents and construct validation. Two studies found a strong correlation with GEARS but none correlated their metrics with patient outcome data. CRPMs are a validated and objective approach for assessing trainee proficiency. Evaluating CRPMs with other robotic-assessment tools will facilitate a multimodal metric evaluation approach to robotic surgery training. Further studies should assess the correlation with clinical outcomes. This review highlights there is significant scope for the development and validation of CRPMs to establish proficiency-based progression curricula that can be translated from a simulation setting into clinical practice.
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ItemHow to do robotic retroperitoneal lymph node dissection in colorectal cancer(WILEY, 2022-11)In select colorectal cancer patients with metastatic retroperitoneal lymph node disease, surgical resection can be performed. We discuss our robotic technique.
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ItemCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in small bowel adenocarcinoma with peritoneal metastasis: a systematic review(WALTER DE GRUYTER GMBH, 2022-12-13)OBJECTIVES: Small bowel adenocarcinoma (SBA) with peritoneal metastasis (PM) is rare and despite treatment with systemic chemotherapy, the prognosis is poor. However, there is emerging evidence that cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) may offer a survival benefit over systemic therapy alone. This systematic review will assess the effectiveness of CRS-HIPEC for SBA-PM. CONTENT: Three databases were searched from inception to 11/10/21. Clinical outcomes were extracted and analysed. SUMMARY: A total of 164 cases of SBA-PM undergoing CRS-HIPEC were identified in 12 studies. The majority of patients had neoadjuvant chemotherapy (87/164, 53%) and complete cytoreduction (143/164, 87%) prior to HIPEC. The median overall survival was 9-32 months and 5-year survival ranged from 25 to 40%. Clavien-Dindo grade III/IV morbidity ranged between 19.1 and 50%, while overall mortality was low with only 3 treatment-related deaths. OUTLOOK: CRS-HIPEC has the potential to improve the overall survival in a highly selected group of SBA-PM patients, with 5-year survival rates comparable to those reported in colorectal peritoneal metastases. However, the expected survival benefits need to be balanced against the intrinsic risk of morbidity and mortality associated with the procedure. Further multicentre studies are required to assess the safety and feasibility of CRS-HIPEC in SBA-PM to guide best practice management for this rare disease.
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ItemNo Preview AvailableCharacteristics of Early-Onset vs Late-Onset Colorectal Cancer A Review(AMER MEDICAL ASSOC, 2021-09)IMPORTANCE: The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer. OBSERVATIONS: Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts. CONCLUSIONS AND RELEVANCE: The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.
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ItemManagement of lateral pelvic lymph nodes by Australasian colorectal surgeons: An insight from the west(WILEY, 2021-12)PURPOSE: Lateral pelvic lymph node dissection (LPLND) for locally advanced low rectal cancer is a common practice in Japan. However, it is not widely performed in western countries. The aim of this survey study is to assess the current practice and management of lateral pelvic lymph nodes by colorectal surgeons in Australasia. METHODS: The authors developed a survey to assess surgeons' assessment and management of lateral pelvic lymph nodes in patients with rectal cancer. The survey was run through the online RedCap® platform in 2019. An electronic link and request to complete the survey was sent to specialist surgeons of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). RESULTS: Ninety-two colorectal surgeons completed the online survey (32% response rate). Eighty percent of participants consider malignant lateral pelvic lymph nodes to represent locoregional and resectable disease. In patients with clinically malignant lateral pelvic lymph nodes on preoperative imaging the majority of respondents (92%) recommend neoadjuvant chemoradiotherapy and 86% would also recommend LPLND. Over half of the surgeons (57%) had no exposure to LPLND during fellowship training and approximately two thirds (62%) do not perform LPLND in their current practice. CONCLUSION: This study highlights the challenges in the management of the lateral pelvic lymph nodes in a western context. The majority of the participating Australasian colorectal surgeons consider malignant lateral pelvic lymph nodes to represent locoregional and resectable disease. The majority also recommend LPLND for clinically malignant lateral pelvic nodes. However, adequate training and experience with LPLND is limited.
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ItemRobotic colorectal surgery in Australia: evolution over a decade(WILEY, 2021-11)BACKGROUND: Despite reports of increasing adoption of robotics in colorectal surgery worldwide, data regarding its uptake in Australasia are lacking. This study examines the trends of robotic colorectal surgery in Australia during the last 10 years. METHODS: Data from patients undergoing robotic colorectal surgery with the da Vinci robotic platform between 2010 and 2019 were obtained. Overall, numbers of specific colorectal procedures across Australia were obtained from the Medicare Benefit Schedule data over the same period. Pearson's correlation analysis was used to determine the statistical trends of overall and specific robotic colorectal procedures over time. RESULTS: A total of 6110 robotic general surgery procedures were performed across Australia during the study period. Of these, 3522 (57.6%) were robotic colorectal procedures. An increasing trend of overall robotic colorectal procedures was seen over 10 years (Pearson's coefficient of 0.875; P = 0.001). While this applied to both the public and private sectors, 90.7% of the procedures were undertaken in the private sector. Restorative rectal resections, rectopexies, and right hemicolectomies accounted for 82.6% of the robotic colorectal procedures performed during this period with an increasing trend seen over time for each intervention. Moreover, a robotic approach was utilized in 12.5%, 41.0% and 9.0% of all restorative rectal resections, rectopexies and right hemicolectomies undertaken in Australia during 2019, respectively. CONCLUSION: Robotic colorectal surgery has increased dramatically in Australia over the last 10 years, especially in the private sector. Penetration of robotic colorectal surgery in the public healthcare system will require focussed cost-benefit evaluations and governmental investment.