Tan Arulampalam’s research while affiliated with Anglia Ruskin University and other places

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 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.

Despite advances in laparoscopic surgery, there is limited evidence on its application and outcomes for the management of adhesional small bowel obstruction(aSBO). Literature defines indications for surgery, without addressing the appropriate approach, traditionally involving laparotomy. This study investigated the feasibility of laparoscopic adhesiolysis for aSBO. This retrospective cohort study included electronic data of patients admitted with aSBO, in a large laparoscopic centre over 3 years. Exclusion criteria applied to non-adhesional SBO, large bowel pathology and conservative treatment. Outcomes included the rate and reason for conversion to laparotomy, complications and length of stay (LOS). 85 patients with CT proven aSBO were included, over 3 years. 69(81.2%) of patients were approached laparoscopically and there was a 32%rate of conversion to laparotomy, due to technical difficulty(54.6%), planned “laparoscopy-first”(22.7%) or intraoperative emergency(18.2%).Those managed laparoscopically had 5 days median LOS compared to 9 in the converted subgroup. Operation note review, revealed a standard operative approach using naso-gastric tube, right sided ports, and collapsed small bowel manipulation to identify the adhesion point. Enterotomy rate was 13.0% and 14.5%of patients required bowel resection from an extraction site. Post-operatively, 20.3%of patients suffered prolonged ileus, 5.8%anastomotic leak, 5.8%required re-operation, 8.7%were readmitted with recurrence and there were 10(14.5%) in-hospital deaths. Our study indicated that laparoscopic adhesiolysis could be feasible for selected patients, with a CT proven transition point. Given the observational findings of this single centre study, further research in laparoscopic units is required, including direct comparison with laparotomy, and converted subgroups, aiming to generate standardised guidelines for the laparoscopic management of aSBO.

Purpose Locally advanced rectal cancer (LARC) is treated by neoadjuvant chemoradiotherapy (NCRT) followed by surgery after restaging with magnetic resonance imaging (MRI). Texture analysis (TA) is a novel imaging biomarker that can assess heterogeneity in MRIs by measuring grey-level intensities distribution. This study hypothesizes that TA of MRI is an imaging biomarker that can predict local recurrence and distant metastasis. Method This is a retrospective analysis of all patients diagnosed with LARC who received NCRT and had MRI scans between 2003–2014 at Colchester University Hospital. Region of interest was drawn around the tumor or its location on T2 MRI images. Six texture parameters were systematically extracted from Textural histograms of post-treatment scans. These parameters were examined to determine their ability to predict local recurrence and distant metastases through Kaplan-Meier survival curves and log-rank tests. Results 113 patients with LARC were included. Two texture parameters were significantly able to predict local recurrence: Entropy (p = 0.033) and mean of positive pixels (MPP) (p = 0.045). Five parameters were able to predict distant metastases: SD(p = 0.015), entropy(p = 0.017), MPP(p = 0.005), skewness (p = 0.046), and Kurtosis (P = 0.019). Upon dichotomizing by the optimal cut-off values, Kaplan-Meier Log rank test showed that entropy and skewness significantly predicted distant metastases. Conclusions MRI textural features are potentially significant imaging biomarkers in predicting local recurrence and distant metastases in LARC.

Abstract Background Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery. Methods A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol. Results A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count. Conclusion Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Background The impact of laparoscopic inguinal hernia repair (IHR) on chronic groin pain (CGP) prevalence, risk and daily activities compared to open IHR is still unclear. Methods A meta-analysis of randomised controlled trials comparing CGP rates in laparoscopic and open IHR was performed. Results 22 trials were included. CGP prevalence decreases significantly 1–2 years post-op and reaches rates as low as 4.69% (laparoscopic) and 6.91% (open) at >5 years. There is a significantly lower risk of CGP following totally extraperitoneal (TEP) than open mesh repair at all follow-up periods (p < 0.05) except for >5 years (p = 0.32). The same trend is not seen when compared to open non-mesh repair or for transabdominal pre-peritoneal repair (TAPP). There is no difference between techniques when CGP is described as moderate and/or affecting daily activities (p = 0.08). Conclusion CGP rates continue to decrease at >5 years follow up. TEP consistently results in a reduction in CGP rates compared to open mesh repair however, this is not functionally significant.

Background Radiomics allows information not readily available to the naked eye to be extracted from high resolution imaging modalities such as CT. Identifying that a cancer has already metastasised at the time of presentation through a radiomic signature will affect the treatment pathway. The ability to recognise the existence of metastases earlier will have a significant impact on the survival outcomes. Aim To create a novel radiomic signature using textural analysis in the evaluation of synchronous liver metastases in colorectal cancer. Methods CT images at baseline and subsequent surveillance over a 5-year period of patients with colorectal cancer were processed using textural analysis software. Comparison was made between those patients who developed liver metastases and those that remained disease free to detect differences in the ‘texture’ of the liver. Results A total of 24 patients were divided into two matched groups for comparison. Significant differences between the two groups scores when using the textural analysis programme were found on coarse filtration (p = 0.044). Patients that went on to develop metastases an average of 18 months after presentation had higher levels of hepatic heterogeneity on CT. Conclusion This initial study demonstrates the potential of using a textural analysis programme to build a radiomic signature to predict the development of hepatic metastases in rectal cancer patients otherwise thought to have clear staging CT scans at time of presentation.

Background: Minimally invasive surgery is still at a relatively early stage throughout the Anglophone Caribbean and robotic surgery has been largely non-existent. There have been many unique obstacles to the introduction of robotic surgery in the Caribbean. Methods: We present a case report to document the initial experience with the use of the FreeHand surgical robot during gynecologic operations in Trinidad & Tobago. Results: Two cases are presented to highlight the use of the FreeHand robot for gynecologic operations. We outline our experiences introducing the FreeHand® robotic arm to facilitate minimally invasive gynecologic surgery in the Caribbean. Conclusions: The FreeHand® system is a good intermediary between conventional laparoscopy and a full surgical robot. We believe this technology can be incorporated into the armamentarium of gynecologic surgeons in resource-poor nations, once there is appropriate training and intra-operative mentoring from experts familiar with the technology.