Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized

BACKGROUND

The clinical syndrome of frailty identified through the assessment of weight loss, gait speed, grip strength, physical activity, and physical exhaustion has been used to identify patients with reduced reserves. We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients.

METHODS

A prospective study was conducted at 2 centers (Singapore and Japan). All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty. All these patients had already had their comorbidities optimized for surgery. The outcome measure was postoperative major complications (defined as Clavien-Dindo type II and above complications).

RESULTS

Eighty-three patients were studied from February 2008 to April 2010. The mean age was 81.5 years (range 75-93 years). The mean comorbidity index was 3.37 (range 0-11). Twenty-six (31.3%) patients were an American Society of Anesthesiologists (ASA) score of 3 and above. Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 (95% confidence interval, 1.433-11.638) when the patient satisfied the criteria for frailty. Albumin <35, ASA >3, comorbidity index >5, and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scores were not predictive of postoperative major complications.

CONCLUSIONS

Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity. Frailty can be used to identify elderly patients needing further optimization before major surgery.

'Start to finish trans-institutional transdisciplinary care': a novel approach improves colorectal surgical results in frail elderly patients

AIM

The frail elderly surgical patient is at increased risk of morbidity after major surgery. A transdisciplinary Geriatric Surgery Service (GSS) has been shown to produce consistently positive results in our institution. A trans-institutional transdisciplinary Start to Finish (STF) programme was initiated incorporating seamless prehabilitation and rehabilitation to enhance the outcome further.

METHOD

Patients who underwent major colorectal resection in Khoo Teck Puat Hospital and were managed under the GSS from January 2007 to December 2014 were included in this prospective study. The STF programme was initiated from January 2012. The surgical outcome of patients managed under the GSS before the initiation of STF was compared with that after its implementation.

RESULTS

There were 57 patients after the initiation of the STF programme compared with 60 patients managed before STF. There were 26.4% and 25% of frail patients in the STF group compared with the non-STF group (P = 0.874). The mean length of hospital stay was significantly shorter in the STF group (8.4 days vs 11.0 days, P = 0.029). Functional recovery in patients available for follow-up at 6 weeks showed 100% (46/46) recovery in the elective STF group who received prehabilitation and 95.7% (45/47) in the elective non-STF group who did not (P = 0.157). There were no significant differences in a Clavien-Dindo complication score of Grade 3 or more and 30-day mortality between the two groups.

CONCLUSION

Through a trans-institutional transdisciplinary approach, we managed to achieve a significantly shorter hospital stay in frail patients having colorectal surgery. All elective patients who received prehabilitation achieved full functional recovery.

Adult intussusception: experience in Singapore

INTRODUCTION

Gastrointestinal intussusception is an uncommon clinical entity in adults and is interestingly distinct from its paediatric form. In adults an identifiable lead lesion is found in the majority of cases, of which a significant percentage are malignant. Its treatment is thus different from that of paediatric intussusception. The present study reviews our experience of treating adult intussusception.

METHODS

A retrospective review of patients with a postoperative diagnosis of gastrointestinal intussusception between January 1997 and December 2002 was conducted. All patients under the age of 18 and cases of rectal prolapse were excluded.

RESULTS

During the 5-year period, there were nine cases of intussusception. There were four male and five female patients, with a mean age of 63.8 years (range 37-85 years). Less than half of the patients (44.4%) presented with acute symptoms. The most common symptoms were abdominal pain and distension. The symptoms were intermittent in 77.8% (7 of 9) of patients. Only two patients had a palpable abdominal mass, while another had signs of acute intestinal obstruction. Computed tomography was the most useful imaging modality, identifying intussusception in six out of six patients. Eight patients had lead lesions occurring at the ileocaecal junction resulting in ileo-colonic intussusception. Of these eight, four were malignant (two adenocarcinomas and two lymphomas). There was one sigmoid-rectal intussusception secondary to adenocarcinoma. All patients were treated operatively. Seven patients were treated with en bloc resection.

CONCLUSION

Although uncommon, surgeons need to be aware of the epidemiology and treatment options for adult intussusception. The symptoms and signs are often non-specific and the surgeon might be faced with the diagnosis only at laparotomy. Computed tomography is the most useful imaging modality. An identifiable organic lesion is present in most cases, of which more than 50% are malignant (especially in the large bowel). Operative treatment is thus prudent. En bloc resection is recommended for ileo-colonic and colo-colonic intussusception. There is, however, a role of initial reduction in selected patients with ileo-ileal intussusception.

Colorectal surgery in octogenarian patients--outcomes and predictors of morbidity

INTRODUCTION

Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer.

METHODS

A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates.

RESULTS

The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification > or =3 and comorbidity index 3 of 5 > or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity.

CONCLUSION

Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

Predictive factors of malignancy in adults with intussusception

INTRODUCTION

Adult intussusception is an unusual entity, and its etiology differs from that in pediatric patients. The aim of this study was to evaluate our experience of 60 adult patients with intussusception and determine if there are any preoperative factors predictive of malignancy.

METHODS

The records of 60 adult patients (>18 years of age) with a diagnosis of intussusception surgically treated at Singapore General Hospital and Changi General Hospital between 1990 and 2004 were retrospectively reviewed. The intussusceptions were classified as enteric or colonic. Preoperative predictive factors of malignancy were analyzed using univariate and multivariate analyses, and P<0.05 was considered statistically significant.

RESULTS

There were 60 patients with a median age of 57.5 years (range 21-85 years). Altogether, 34 (56.7%) patients were male, and there were 31 enteric and 29 colonic intussusceptions. A lead point was identified in 54 patients (90%). A total of 22 (36.7%) patients presented with intestinal obstruction, and the correct preoperative diagnosis of intussusception was made in 31 patients (51.7%). Computed tomography was the most useful diagnostic modality, correctly identifying an intussusception in 24 of 30 patients. A malignant pathology was present in 8 of 31 (26%) enteric versus 20 of 29 (69%) colonic intussusceptions. Age (P=0.009), the presence of anemia (P<0.001), and the site of the intussusception (P=0.001) showed significant differences between the benign and malignant groups by univariate analyses. On multivariate analysis, intussusception in the colon (P=0.004) and the presence of anemia (P=0.001) were independent predictive factors of malignancy.

CONCLUSIONS

Adult intussusception is most commonly secondary to a pathologic lead point. The site of intussusception in the colon and the presence of anemia are independent preoperative predictors of malignancy. All colonic intussusceptions should be resected en bloc without reduction, whereas a more selective approach can be applied for enteric intussusceptions.

Advances in surgical management for locally recurrent rectal cancer: How far have we come?

Locally recurrent rectal cancer (LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.

A collaborative transdisciplinary "geriatric surgery service" ensures consistent successful outcomes in elderly colorectal surgery patients

BACKGROUND

We hypothesized that a dedicated collaborative transdisciplinary Geriatric Surgery Service (GSS) will improve care for elderly colorectal surgery patients.

METHODS

Patients older than 75 years of age who underwent major colorectal surgery were included in this study. The Geriatric Surgery Service employed a transdisciplinary, collaborative model of care. There were frequent quality reviews and a patient-centered culture was ensured. Treatment protocols and checklists were instituted. Perioperative outcome data were collected prospectively between 2007 and 2009. These data were compared to those from similar patients not managed by the service. Success and failure of surgical treatment of the two groups were analyzed using CUSUM methodology. Failure was defined as mortality, prolonged hospital stay for any reason, including morbidity, and failure to regain preoperative function by 6 weeks.

RESULTS

Twenty-nine patients managed by the GSS were compared to 52 patients who underwent standard treatment. The median age of the patients managed by the GSS was higher but there was no difference in the ASA score and predicted morbidity scores based on the POSSUM model. The GSS achieved lower mortality and major complication rates. A large majority (84.6%) of the patients managed by the GSS returned to preoperative functional status by 6 weeks. The GSS was able to produce a trend of successively desired outcomes consistently leading to the CUSUM curve exhibiting a sustained downward slope. This was in contrast to patients not managed by the GSS.

CONCLUSION

The Geriatric Surgery Service, through its transdisciplinary, collaborative care processes, was able to achieve sustained superior outcomes compared to standard management.

Randomized clinical trial of 0.2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy

BACKGROUND

Open haemorrhoidectomy is associated with considerable postoperative pain and discomfort. This study assessed whether glyceryl trinitrate (GTN) ointment promotes wound healing and reduces pain after open haemorrhoidectomy.

METHODS

A randomized prospective double-blind placebo-controlled trial was conducted. Patients were randomized to either 0.2 per cent GTN ointment or placebo ointment (petroleum jelly). Patients were asked to fill in a pain diary. Complete healing was defined as complete epithelialization.

RESULTS

There were 40 patients in the GTN group and 42 in the placebo group. There were no statistically significant differences in sex, weight, type of haemorrhoid, type of surgery (emergency or elective), number of haemorrhoids excised, duration of surgery, hospital stay and complication rate between the groups. Pain scores and analgesic use were not significantly different. By week 3, however, 17 patients in the GTN group had completely epithelialized wounds compared with eight patients in the placebo group (P = 0.021). Only one patient who received GTN experienced headache requiring discontinuation of the ointment.

CONCLUSION

TGN 0.2 per cent ointment improved wound healing rates, but did not reduce pain in this study.

The role of traditional Chinese medicine in colorectal cancer treatment

Surgery, chemotherapy and radiotherapy have been the mainstay of colorectal cancer treatment. There is however current intense research on traditional Chinese medicine (TCM) as novel or additional treatment methods for colorectal cancer. This article reviews the current use of TCM in colorectal cancer so as to increase the awareness of colorectal surgeons. The pathogenesis of colorectal cancer according to TCM is discussed. TCM has been used successfully during the perioperative period to relieve intestinal obstruction, reduce postoperative ileus and reduce urinary retention after rectal surgery. Good results have been reported in the treatment of the complications of chemotherapy and radiation enterocolitis. Favourable results have also been shown in the use of TCM either alone or in combination with chemotherapy to treat advanced colorectal cancer. Molecular studies have shown some TCM compounds to reduce tumour cell proliferation and induce apoptosis. Although the reported results of TCM have been exciting thus far, problems of lack of consensus on treatment regimes and questions on the reliability, validity and applicability of published studies prevent its widespread use. There is now an urgent need for colorectal surgeons to work with TCM physicians in the continuing research on this 6,000-year-old art so as to realize its full potential for our patients.

Distribution of the first metastatic lymph node in colon cancer and its clinical significance

INTRODUCTION

The pattern of distribution of lymph node metastasis in resected specimens of colon cancer has been rarely reported in the English literature. The aim of this study was to determine the location of the first metastatic lymph node, giving insight into the drainage pattern of colon cancer lymphatics.

METHOD

All lymph nodes in the mesentery of the resected specimen were carefully harvested and their precise locations documented. Patients with a single metastatic node in the resected specimen were included in the study.

RESULTS

Ninety-three patients with only one metastatic lymph node found on histology were studied. The mean number of lymph nodes per specimen was 22.3 (range: 8-72). The patients' first metastatic node was not directly below the tumour in 48% of cases. The first metastatic node was found in the region either along the feeding vessels (skipping the pericolic nodes) or in the pericolic area outside 5 cm on either side of the tumour edge in 18% of cases. No factors were found to be predictive for lymph node metastasis occurring elsewhere other than in the pericolic region just below the tumour.

CONCLUSION

Although there has been recent resurgence of interest in using sentinel node biopsy to limit surgical dissection to facilitate minimally access and natural orifice surgery, the present study is a warning that this may compromise oncological clearance. Radical surgery should remain standard practice for colorectal cancer.

Impact of surgical delay on outcomes in elderly patients undergoing emergency surgery: A single center experience

AIM

To determine predisposing factors leading to surgical delay in elderly patients with acute abdominal conditions and its impact on surgical outcomes.

METHODS

A retrospective review of a total of 144 patients aged 60 years and older who had undergone emergency abdominal surgery between 2010 and 2013 at a regional general hospital was analysed. The operations analysed were limited to perforated or gangrenous viscus and strangulated hernia. Patient demographic features, time taken to obtain a computed tomography scan, time taken to surgery and the impact on postoperative morbidity and mortality were analysed.

RESULTS

The mean age was 70.5 ± 9.1 years and median time taken to surgery was 9 h. The overall mortality and complication rates (Clavien Dindo 3 and above) were 9% and 13.1% respectively. Diabetes mellitus was a significant predisposing factor which had an impact on surgical delays. Delays in surgery more than 24 h led to higher complication rates at 38.9% (P = 0.003), with multivariate analysis confirming it as an independent factor. Delays in obtaining a computed tomography (CT) scan was also shown to result in higher complication rates (Clavien Dindo 3 and above).

CONCLUSION

Delays in performing emergency surgery in elderly lead to higher complication rates. Obtaining CT scans early also may facilitate prompt diagnosis of certain abdominal emergencies where presentation is more equivocal and this may lead to improved surgical outcomes.

Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre

BACKGROUND

Mirizzi syndrome is uncommon. It is, however, clinically important, as it is associated with an increased incidence of bile duct injury and demands more complex surgical techniques.

METHODS

A retrospective review of 24 consecutive cases of Mirizzi syndrome that arose between January 1997 and July 2002 was performed. A total of 1881 cholecystectomies were performed during that period.

RESULTS

Of the 24 patients, 19 (79.2%) had Mirizzi type I, four (16.7%) had type II, while one (4.2%) had type III disease. Only 54.2% of patients were symptomatic prior to presentation. One-third of patients had normal liver function tests. Ultrasonography and computed tomography were not helpful in diagnosing this entity. Endoscopic retrograde cholangiopancreatography (ERCP) was useful to identify cholecystocholedochal fistulas and to allow therapeutic endoscopic stenting but failed to pick up the syndrome in half of the patients. Inadvertent bile duct injury occurred in four patients (16.7%), all occurred in patients without a preoperative diagnosis. Three of the four injuries occurred during operations by a senior registrar rather than a consultant. Mirizzi type I was managed with either total or subtotal cholecystectomy, while types II and III cases were managed with either T-tube insertion or biliary bypass procedures. Bile duct injury was managed with T-tube successfully in one patient while the rest went on to biliary bypass operations. All except one patient had good functional outcomes on follow up.

CONCLUSION

The preoperative diagnosis of Mirizzi syndrome is a challenge. Only constant vigilance during intraoperative dissection of the Calot's triangle will reduce the incidence of bile duct injury in Mirizzi syndrome that can occur in both open and laparoscopic surgery.

Hemorrhoidectomy - making sense of the surgical options

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery

BACKGROUND AND AIMS

High ligation of the inferior mesenteric artery may jeopardize blood supply to the proximal bowel. We undertook this study to review the clinical features and outcomes of patients who developed proximal bowel necrosis after high ligation of the inferior mesenteric artery, and to assess the incidence and the risk factors for this complication.

MATERIALS AND METHODS

A retrospective analysis of patients undergoing high or low ligation for sigmoid colon and rectal cancer with a primary anastomosis between April 2004 and March 2009 was performed. Patient and tumor characteristics and the incidence of bowel necrosis were reviewed.

RESULTS

Four hundred and nine patients were included to the analysis. Six out of 302 patients (2.0%) with high ligation developed proximal bowel necrosis, while the remaining 107 patients with low ligation did not suffer from this complication. All patients who developed proximal bowel necrosis underwent secondary surgery with resection of necrotic bowel. The pathological examination of the resected specimen revealed mucosal to transmural ischemic necrosis without the evidence of vascular thrombosis or embolic occlusion. Univariate analysis revealed that advanced age, cerebrovascular disease, and hypertension were significantly associated with proximal bowel necrosis. Multivariate analysis demonstrated that cerebrovascular disease was an independent predictor of this complication. Of these six patients, two died from associated complications.

CONCLUSIONS

Proximal bowel necrosis after high ligation is potentially fatal, and this report provides a warning in clinical settings where high ligation is indicated. Further studies are warranted to evaluate its distinct relationship with high ligation and to clarify whether low ligation would be a safeguard.

Which octogenarians do poorly after major open abdominal surgery in our Asian population?

BACKGROUND

As the elderly population grows and surgeons are faced with more octogenarians, there is a need to know how our Asian patients fair after major surgery.

METHODS

A retrospective review of 125 octogenarians who underwent major abdominal surgery between January 1997 and September 2003 was performed. Preoperative condition was assessed using a weighted index of comorbidity used in Charlson Comorbidity Index and classification of patients according to the American Society of Anaesthesiologists (ASA). Outcome was measured as to whether complications developed, 30-day mortality and whether there was return to premorbid function.

RESULTS

The patients had a mean age of 84.6 years (range: 80-106). Nearly half (48.8%, n = 61) the cases were emergency cases. The median index of comorbidity was 3, and 29.6% of patients were classified either ASA III or IV. The operations were mostly stomach, small bowel or large bowel resection. Multivariate analysis revealed that emergency operations were associated with significantly increased odds of morbidity. The overall 30-day mortality was 5.6%, being only 4.7% for elective cases, despite high morbidity rates. ASA classification, comorbidity index >5, development of acute coronary syndrome and anastomotic leakage were found on multivariate analysis to significantly increase the odds of mortality. For elective cases, 82.8% of patients were able to return to their premorbid functional status. Development of complications and comorbidity index >5 were found to predict failure of its occurrence. Low serum albumin and haemoglobin and renal impairment were also predictors of adverse outcome.

CONCLUSIONS

Efforts to improve outcome in geriatric surgery patients should emphasize a shift of attitude towards elective surgery rather than doing emergency operations when complications occur and also target the optimization of predictors of adverse outcome. Octogenarians should not be denied elective surgery.

Current research and treatment for gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and have gained considerable research and treatment interest, especially in the last two decades. GISTs are driven by mutations commonly found in the KIT gene and less commonly in the platelet-derived growth factor receptor alpha gene, BRAF gene and succinate dehydrogenase gene. GISTs behave in a spectrum of malignant potential, and both the tumor size and mitotic index are the most commonly used prognostic criteria. Whilst surgical resection can offer the best cure, targeted therapy in the form of tyrosine kinase inhibitors (TKIs) has revolutionized the management options. As the first-line TKI, imatinib offers treatment for advanced and metastatic GISTs, adjuvant therapy in high-risk GISTs and as a neoadjuvant agent to downsize large tumors prior to resection. The emergence of drug resistance has altered some treatment options, including prolonging the first-line TKI from 1 to 3 years, increasing the dose of TKI or switching to second-line TKI. Other newer TKIs, such as sunitinib and regorafenib, may offer some treatment options for imatinib-resistant GISTs. New molecular targeted therapies are being evaluated, such as inhibitors of BRAF, heat shock protein 90, glutamine and mitogen-activated protein kinase signaling, as well as inhibitors of apoptosis proteins antagonist and even immunotherapy. This editorial review summarizes the recent research trials and potential treatment targets that may influence our future patient-specific management of GISTs. The current guidelines in GIST management from Europe, North America and Asia are highlighted.

Randomized single-blind clinical trial of intradermal methylene blue on pain reduction after open diathermy haemorrhoidectomy

BACKGROUND

Open haemorrhoidectomy has been associated with considerable postoperative pain and discomfort. Perianal intradermal injection of methylene blue has been shown to ablate perianal nerve endings and may bring about temporary pain relief after haemorrhoidectomy. We hypothesized that the administration of intradermal methylene blue would reduce postoperative pain during the initial period after surgery.

METHOD

A randomized, prospective, single-blind placebo-controlled trial was conducted. Patients were randomized to intradermal injection at haemorrhoidectomy of either 4 ml 1% methylene blue and 16 ml 0.5% marcaine or of 16 ml 0.5% marcaine and 4 ml saline prior to surgical dissection. Patients were asked to fill in a pain diary with a visual analogue scale. The primary outcome measure was pain score and analgesic use. Secondary outcomes were complications.

RESULTS

There were 37 patients in the methylene blue arm and 30 patients in the placebo arm. There were no statistically significant differences in the sex, type of haemorrhoid, number of haemorrhoids excised, duration of surgery or hospital stay. The mean pain scores were significantly lower and the use of paracetamol was also significantly less in the methylene blue group during the first three postoperative days. The risk ratio of acute urinary retention occurring when methylene blue was not used was 2.320 (95% CI 1.754-3.067). Other complication rates were not significantly different.

CONCLUSION

Perianal intradermal injection of methylene blue was useful in reducing the initial postoperative pain of open haemorrhoidectomy.

Randomized clinical trial comparing LigaSure haemorrhoidectomy with open diathermy haemorrhoidectomy

BACKGROUND

Milligan-Morgan excision haem-orrhoidectomy remains a very popular treatment modality for third and fourth degree haemorrhoids due to its cost effectiveness and good long-term results. The LigaSure tissue-sealing device is an alternative technique used in haemorrhoidectomy that has been shown to produce favourable results. The aim of this study was to assess the effectiveness of the LigaSure tissue sealing device in comparison with conventional diathermy haemorrhoidectomy.

METHODS

A prospective clinical trial was conducted. Patients with newly diagnosed haemorrhoids requiring haemorrhoidectomy were randomized to either LigaSure haemorrhoidectomy or diathermy haemorrhoidectomy. Surgical technique and postoperative care was standardized. Outcome measures were operative time and bleeding, postoperative pain (measured on a visual analogue scale) and rate of wound healing.

RESULTS

We randomized 44 patients, 22 to LigaSure and 22 to diathermy; 43 patients were evaluated. They were aged between 19 and 71 years. There were no differences in patient demographics or type of haemorrhoid being operated on. LigaSure haemorrhoidectomy had a significantly lower mean operative time and intraoperative bleeding. At 3 weeks after surgery, haemorrhoidectomy performed with LigaSure had an odds ratio for complete epithelialization of 3.1 over diathermy (95% CI 1.2-8.2). There was no difference in postoperative pain.

CONCLUSION

LigaSure haemorrhoidectomy is superior to diathermy for open haemorrhoidectomy.

Fiber and colorectal diseases: separating fact from fiction

Whilst fruits and vegetables are an essential part of our dietary intake, the role of fiber in the prevention of colorectal diseases remains controversial. The main feature of a high-fiber diet is its poor digestibility. Soluble fiber like pectins, guar and ispaghula produce viscous solutions in the gastrointestinal tract delaying small bowel absorption and transit. Insoluble fiber, on the other hand, pass largely unaltered through the gut. The more fiber is ingested, the more stools will have to be passed. Fermentation in the intestines results in build up of large amounts of gases in the colon. This article reviews the physiology of ingestion of fiber and defecation. It also looks into the impact of dietary fiber on various colorectal diseases. A strong case cannot be made for a protective effect of dietary fiber against colorectal polyp or cancer. Neither has fiber been found to be useful in chronic constipation and irritable bowel syndrome. It is also not useful in the treatment of perianal conditions. The fiber deficit - diverticulosis theory should also be challenged. The authors urge clinicians to keep an open mind about fiber. One must be aware of the truths and myths about fiber before recommending it.

Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience

INTRODUCTION

The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery.

METHODS

Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality.

RESULTS

There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6-2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3-125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se.

CONCLUSIONS

Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.

Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision

BACKGROUND

Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program.

METHODS

A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously.

RESULTS

Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery.

CONCLUSIONS

Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.

Managing elderly with colorectal cancer

The aging population is an increasing healthcare concern in developing countries. In Singapore, 25% of the local population are expected to be older than 65 years old by 2030. Colorectal cancer (CRC) is ranked third most diagnosed cancers worldwide with up to 1.8 million new cases diagnosed in 2018. 60% of newly diagnosed CRC are among patients who are 70 years or older and hence majority of these patients will invariably face challenges with frailty and multiple comorbidities that require appropriate assessment and stratification. The standard of care in patients with stage I or II CRC is surgery with curative intent. For patients with stage III CRC, upfront surgical resection of tumor along with adjuvant chemotherapy is the internationally recommended treatment approach. As for those patients with metastatic disease, they are usually managed within a multidisciplinary team and considered for surgical resection if deemed feasible. Elderly patients are mostly burdened with frailty, functional dependency and existing co-morbidities, all of which are predictors of early postoperative mortality and morbidity in patients with CRC. This article thus aims to review existing evidence to discuss the intricate decision-making process for the surgical management of elderly patient with CRC.

Improving prediction of lateral node spread in low rectal cancers--multivariate analysis of clinicopathological factors in 1,046 cases

INTRODUCTION

This study aims to search for independent predictors of lateral node metastasis in low rectal cancers.

MATERIALS AND METHODS

We analyzed 1,046 patients who underwent curative resection for lower rectal cancer in our prospectively collected database. All lymph nodes were dissected from the fresh specimen, and their locations were documented prospectively according to the classification by the Japanese Society of Cancer of the Colon and Rectum.

RESULTS

More than 35% of the patients had demonstrated upward nodal metastasis in the direction of the inferior mesenteric vessels, while 11% demonstrated lateral node metastasis, which was present in 17.3% of patients with T3 and T4 lesions. Multivariate analysis revealed five factors to be statistically significant independent predictors of lateral node metastasis: female sex, tumors that were not well differentiated, pathological T3 and above, positive microscopic lymphatic invasion, and positive mesorectal nodes. Using the variables sex, differentiation, T stage, and mesorectal nodes as risk factors, because these could be elucidated preoperatively, the presence of lateral node metastasis was then analyzed according to the number of positive risk factors. When there were fewer than three positive factors, the risk of lateral nodal spread was low (4.5%). When three or more risk factors were positive, the odds of lateral node metastasis were more than 7.5 times higher (p < 0.001).

CONCLUSION

The findings of this study provide a scoring system that can be used to guide the clinician to the presence of lateral node metastasis in low rectal cancers.