https://link.springer.com/content/pdf/10.1007%2Fs11605-020-04623-5.pdf

Telemedicine: Patient-Provider Clinical Engagement During the COVID-19 Pandemic and Beyond.

Lockdown during the COVID-19 pandemic compelled urologists to change access to healthcare, especially for oncology patients. Teleconsultation is a safe way to receive medical advice without a risk of infection, and was implemented urgently in our academic centres. Our purpose was to evaluate patient and physician satisfaction with teleconsultation set up during the COVID-19 pandemic. From March 16th 2020, all face-to-face consultations were cancelled in France, except for emergencies. Teleconsultation was started immediately by five senior urologists in two academic hospitals. All patients received an email survey including the validated Teleconsultation Satisfaction Questionnaire (TSQ) and demographic questions. Data were collected prospectively. Physicians also responded to the TSQ. Patient satisfaction was measured objectively with the validated 14-item TSQ. Each item was scored on a 5-point Likert scale. Factors associated with positive satisfaction with teleconsultation were assessed by multivariable logistic regression. Overall, 105 patients replied to the survey (91.3%). Median age was 66 years (IQR: 55‒71) and 95 were men (90.5%). Median overall TSQ score was 67 (IQR: 60‒69); teleconsultation was judged to be a good experience by 88 patients (83.8%) and four physicians (80%). Patients who met their surgeon for the first time were more likely to have a good experience (OR = 1.2 [95% CI 1.1‒1.5], p = 0.03). Introduced rapidly during the COVID-19 lockdown, urology teleconsultation attained a high level of satisfaction among both patients and physicians. A major change in telemedicine use is foreseen in the post COVID-19 era.

/pdf/preliminary-assessment-of-patient-and-physician-satisfaction-2a8w1cgbml.pdf

Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic.

Hartmann's procedure, colonic resection with an end colostomy and rectal closure, is used in a variety of surgical emergencies. It is a common surgical procedure that is often practiced in patients with colonic obstruction and colonic perforation, resolving the acute clinical situation in the majority of cases. Reversal of Hartmann's procedure with restoration of bowel continuity occurs in a significantly low percentage of patients. There are several reasons contributing to the fact that many patients remain with a permanent colostomy following Hartmann's procedure. These include factors related to the patients' clinical status but also to the significant difficulty and morbidity related to the surgical reversal of Hartmann's procedure. The aim of this study was to review the factors related to the fairly low percentage of patients undergoing Hartmann's reversal as well as surgical techniques that could help surgeons restore intestinal continuity following Hartmann's procedure and deal with the postoperative outcomes.

Reversal of Hartmann’s procedure: still a complicated operation

BACKGROUND A stoma has severe impact on the patient's quality of life (QoL). Postoperative home community follow-up by teleconsultation (TC) and stoma nurses may reduce the burden of travel and improve QoL. METHODS A university hospital and five district medical centres participated. Patients with a stoma were randomized to follow-up by either TC (intervention) or hospital (control). Stoma nurses performed the clinical examination at the TC studio, aided remotely by hospital nurses and surgeons. The primary endpoint was the EQ-5D™ index score; secondary endpoints were the Stoma Quality-of-Life Scale, the OutPatient Experiences Questionnaire, and use of hospital resources. RESULTS A total of 110 patients were randomized to hospital (58 patients) or TC (52) follow-up; 64 patients (hospital 38, TC 26) were followed for more than 12 months and 246 consultations (hospital 151, TC 95) were performed. There were no differences in QoL: EQ-5D™ index score (P = 0·301) and EQ-5D™ visual analogue scale (VAS) score (P = 0·775); Work/Social Function (P = 0·822); Sexuality/Body Image (P = 0·253) and Stoma Function (P = 0·074). Hospital follow-up performed better for organization of care (staff collaboration, P = 0·004; met same persons, P = 0·003) and communication (surgeon understandable, P < 0·001; surgeon caring P = 0·003). TC did not increase the number of hospital consultations (P = 0·684) and reduced the number of journeys of more than 8 h (P = 0·007). CONCLUSION Telemedicine follow-up by stoma nurses did not improve the QoL of patients, but decreased the readmission rate and burden of travel. Registration number NCT01600508 ( https://www.clinicaltrials.gov).

https://bjssjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/bjs.11491

Telemedicine in postoperative follow‐up of STOMa PAtients: a randomized clinical trial (the STOMPA trial)

Robotic telesurgery is a new concept in surgical care that has gained relevance over the past two decades. Now, with the introduction of 5G mobile networks, this concept is becoming practical. Here, we report that surgeons successfully performed complex transoral laser microsurgeries on the vocal cords of an adult human cadaver located 15 km away from them. This was possible thanks to a high bandwidth and ultra-low latency 5G telecommunication system, which allowed for precise remote control of robotic instruments and full HD ( $1920\times 1280$ pixels) 3D visualization of the surgical site. During the operation, the mean video transmission latency was 102±9 ms with the maximum latency being 140 ms, but this was observed during less than 1% of the operation time. This latency did not cause any deterioration in surgeons’ performance. Our results demonstrate that surgical expertise can be exploited and shared efficiently using the new 5G telecommunication standard. This is critical for highly specialized operations such as the microsurgeries demonstrated here, which require surgical expertise that are not widely available. Therefore, the possibility to operate from a distance can bring significant benefits to healthcare systems, reducing costs and enhancing treatment quality for patients. In addition, it makes telementoring a reality, allowing expert surgeons to be present virtually in multiple operating rooms to guide and train less experienced colleagues.

5G Robotic Telesurgery: Remote Transoral Laser Microsurgeries on a Cadaver

Safe and effective implementation of remote surgery and telementoring can have significant limitations. Fifth-generation (5G) wireless networks could be useful in overcoming these drawbacks. As a proof of concept, the authors present technical and clinical details of two procedures assisted by telementoring using 5G that were also broadcast live. Secure remote access advice.

5G-assisted telementored surgery

Anastomotic leak (AL) is the most feared complication in colorectal surgery. Indocyanine green (ICG) fluorescence angiography allows for real-time intraoperative evaluation of bowel perfusion. This study aimed to assess the impact of ICG on perioperative outcomes in patients treated with transanal total mesorectal excision (TaTME) for rectal cancer. Comparative study based on a retrospective analysis of prospectively collected data, to validate the use of ICG assessment (ICGA) during TaTME (November/2011–June/2018). The primary outcome was the clinical AL rate. The secondary outcomes included modification of proximal colonic transection, anastomotic redo, additional surgical maneuvers and surgical morbidity. Two hundred and eighty-four patients were included, 204 (71.8%) in non-ICG group and 80 (28.2%) in ICG group. No significant differences were found in patient and tumor features. Mean anastomotic height was 4.85 cm vs. 5.04 cm (p = 0.500), diverting stoma was constructed in 205 patients (72.1% vs. 72.5%; p = 0.941). Fluorescence angiography modified the surgical plan in 23 patients (28.7%). AL was diagnosed in 23 patients (11.3%) in the non-ICG group and in two patients (2.5%) in the ICG group (p = 0.020). Postoperative intraabdominal collection was diagnosed in 19 patients (7.4% vs. 5.1%; p = 0.490), and reintervention was needed in 24 patients (10.8% vs. 7.6%; p = 0.420). Median length of hospital stay was 6.0 (IQR 5.0–9) vs. 4.0 (IQR 3.0–8.5) (p = 0.005). ICGA was found as independent protective factor for AL in the multivariate analysis of the whole cohort (n = 284) (OR 0.142; 95% CI 0.032–0.633; p = 0.010). ICG fluorescence angiography modified the proximal colonic transection in more than one-quarter of patients, leading to a significant decrease of AL rate.

The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study.

Indocyanine green has been widely employed as a secure and easy technique for sentinel lymph node mapping in different types of cancer. Nonetheless, the usage of Indocyanine green has not been fully implemented due to the heterogeneous results found in published studies. Thus, the objective of this meta-analysis is to evaluate the overall performance of Indocyanine green for sentinel lymph node mapping and node metastasis in patients undergoing colorectal cancer surgery. An extensive systematic search was performed to identify relevant studies in English and Spanish with no time limit restrictions. For the meta-analysis, a hierarchical summary receiver operating characteristic curve (HSROCs) was constructed, and quantitative data synthesis was performed using random effects models. Specificity, sensitivity, positive, and negative likelihood ratios were obtained from the corresponding HSROC. Between-study heterogeneity was visually evaluated using Galbraith plot, and publication bias was quantified using Deeks’ method. A total of 11 studies were included for analysis. The pooled detection rate for sentinel lymph node mapping was 91% (80–98%). Covariates significantly influencing the pooled detection rate were having colon cancer (estimate: 1.3001; 1.114 to 1.486; p < 0.001) and the usage of a laparoscopic approach (estimate: 1.3495; 1.1029 to 1.5961; p < 0.001). The performance of Indocyanine green for the detection of metastatic lymph nodes yielded an area under the roc curve of 66.5%, sensitivity of 64.3% (51–76%), and specificity of 65% (36–85%). Indocyanine green for the detection of sentinel lymph node mapping demonstrates better accuracy when used in colonic cancer and by a laparoscopic approach. Nevertheless, its overall performance for the detection of lymph node metastasis is poor.

Performance of Indocyanine green for sentinel lymph node mapping and lymph node metastasis in colorectal cancer: a diagnostic test accuracy meta-analysis

For patients with mid and distal rectal cancer, robust evidence on long-term outcome and causal treatment effects of transanal total mesorectal excision (TaTME) is lacking. This multicentre retrospective cohort study aimed to assess whether TaTME reduces locoregional recurrence rate compared to laparoscopic total mesorectal excision (LapTME). Consecutive patients with rectal cancer within 12 cm from the anal verge and clinical stage II-III were selected from three institutional databases. Outcome after TaTME (Nov 2011 - Feb 2018) was compared to a historical cohort of patients treated with LapTME (Jan 2000 - Feb 2018) using the inverse probability of treatment weights method. The primary endpoint was three-year locoregional recurrence. A total of 710 patients were analysed, 344 in the TaTME group and 366 in the LapTME group. At 3 years, cumulative locoregional recurrence rates were 3.6% (95% CI, 1.1–6.1) in the TaTME group and 9.6% (95% CI, 6.5–12.7) in the LapTME group (HR = 0.4; 95% CI, 0.23–0.69; p = 0.001). Three-year cumulative disease-free survival rates were 74.3% (95% CI, 68.8–79.8) and 68.6% (95% CI, 63.7–73.5) (HR = 0.82; 95% CI, 0.65–1.02; p = 0.078) and three-year overall survival 87.2% (95% CI, 82.7–91.7) and 82.2% (95% CI, 78.0–86.2) (HR = 0.74; 95% CI, 0.53–1.03; p = 0.077), respectively. In patients who underwent sphincter preservation procedures, TaTME was associated with a significantly better disease-free survival (HR = 0.78; 95% CI, 0.62–0.98; p = 0.033). These findings suggest that TaTME may improve locoregional recurrence and disease-free survival rates among patients with mid and distal locally advanced rectal cancer.

/pdf/three-year-outcome-after-transanal-versus-laparoscopic-total-xp73vapw1c.pdf

Three-year outcome after transanal versus laparoscopic total mesorectal excision in locally advanced rectal cancer: a multicenter comparative analysis.

Total mesorectal excision (TME) is the cornerstone of rectal cancer treatment. Transanal total mesorectal excision (TaTME), first described in 2010, is a new technique that is being adopted by many centers due to the solution of technical and anatomical challenges encountered during rectal cancer treatment by either an open or laparoscopic approach, such as narrow, and/or male pelvis and/or obese patient [1]. Evolution of the technique has led to combined transanal and transabdominal total mesorectal excision, called the Cecil approach [2]. Several technical articles regarding the down-to-up approach have been published, focussing on the most complicated steps [1–4]. The following are the key steps in a successful Cecil approach: introduction of the Gelport, placement of the trocars, purse-string, finding the plane of dissection, rendez-vous with the abdominal team and anastomosis. A correct purse-string of the rectum is crucial for the optimal progress of the procedure [1]. It sets the distal margin for resection, it creates a sealed cavity that gets distended making the mesorectal dissection feasible and it prevents tumor and stool spillage into the pelvic cavity. This video illustrates a purse-string break and the surgical approach to this complication. Case description

A. Otero-Piñeiro

Papers

5G-assisted telementored surgery

The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study.

Performance of Indocyanine green for sentinel lymph node mapping and lymph node metastasis in colorectal cancer: a diagnostic test accuracy meta-analysis

Three-year outcome after transanal versus laparoscopic total mesorectal excision in locally advanced rectal cancer: a multicenter comparative analysis.

Purse-string rupture: pitfalls of transanal total mesorectal excision (Cecil approach).