Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse

BACKGROUND

The objectives of this study were to compare both subjective clinical outcomes and the objective stress response of laparoscopic and open abdominal rectopexy in patients with full-thickness rectal prolapse. Abdominal rectopexy for patients with rectal prolapse is well suited for a laparoscopic approach as no resection or anastomosis is necessary.

METHODS

Forty patients with a full-thickness rectal prolapse were randomized before operation to a laparoscopic group and an open group. They agreed to conform to a clinical pathway (CP) of liquid diet (CP1) and full mobility (CP2) on day 1, solid diet (CP3) on day 2 and discharge (CP4) before day 5. Their compliance was monitored by an assessor blinded to the operative group, who also rated pain and mobility. Patient-controlled morphine use was documented. Neuroendocrine and immune stress response and respiratory function were measured.

RESULTS

Some 75 per cent of all clinical pathway objectives of early recovery were achieved in the laparoscopic group compared with 37 per cent in the open group (P < 0.01). Significant differences in favour of laparoscopy were noted with regard to narcotic requirements, and pain and mobility scores. Differences in objective measures of stress response favouring laparoscopy were found for urinary catecholamines, interleukin 6, serum cortisol and C-reactive protein. No differences were noted in respiratory function but significant respiratory morbidity was greater in the open group (P < 0.05). None of the measured outcomes, subjective or objective, favoured the open group apart from operating time, which was significantly shorter (153 versus 102 min; P < 0.01).

CONCLUSION

This study has demonstrated significant subjective and objective differences in favour of a laparoscopic technique for abdominal rectopexy. The advantages were all short term but no evidence of any adverse effect on longer-term outcomes was observed.

Risk factors for prolonged ileus after resection of colorectal cancer: an observational study of 2400 consecutive patients

OBJECTIVE

Prolonged ileus-the failure of postoperative ileus to resolve within a few days after major abdominal surgery-leads to significant medical consequences for the patient and costs to the hospital system. The aim of this retrospective analysis of prospectively collected data was to identify independent preoperative and intraoperative risk factors for prolonged ileus in a large consecutive series of patients who had undergone resection for colorectal cancer.

METHODS

Patients were drawn from a hospital registry of 2400 consecutive resections over the period 1995-2009. Thirty-four potential predictors of prolonged ileus were analyzed by logistic regression.

RESULTS

Prolonged ileus occurred in 14.0% of patients. Statistically significant independent predictors of prolonged ileus were male sex (OR: 1.7, P < 0.001), peripheral vascular disease (OR: 1.8, P < 0.001), respiratory comorbidity (OR: 1.6, P < 0.001), resection at urgent operation (OR: 2.2, P < 0.001), perioperative transfusion (OR: 1.6, P < 0.010), stoma constructed (OR: 1.4, P < 0.001), and operation lasting ≥3 hours (OR: 1.6, P < 0.001).

CONCLUSIONS

These features can be used to alert medical and nursing staff to patients likely to experience prolonged ileus after bowel resection so that they can be monitored closely in the postoperative period and available treatments targeted toward them. These features may also be useful in the research context to facilitate the more efficient selection of high-risk patients as subjects in clinical trials of prevention or treatment.

Multicenter randomized trial of centralized nurse-led telephone-based care coordination to improve outcomes after surgical resection for colorectal cancer: the CONNECT intervention

PURPOSE

To investigate the effectiveness of a centralized, nurse-delivered telephone-based service to improve care coordination and patient-reported outcomes after surgery for colorectal cancer.

PATIENTS AND METHODS

Patients with a newly diagnosed colorectal cancer were randomly assigned to the CONNECT intervention or usual care. Intervention-group patients received standardized calls from the centrally based nurse 3 and 10 days and 1, 3, and 6 months after discharge from hospital. Unmet supportive care needs, experience of care coordination, unplanned readmissions, emergency department presentations, distress, and quality of life (QOL) were assessed by questionnaire at 1, 3, and 6 months.

RESULTS

Of 775 patients treated at 23 public and private hospitals in Australia, 387 were randomly assigned to the intervention group and 369 to the control group. There were no significant differences between groups in unmet supportive care needs, but these were consistently low in both groups at both follow-up time points. There were no differences between the groups in emergency department presentations (10.8% v 13.8%; P = .2) or unplanned hospital readmissions (8.6% v 10.5%; P = .4) at 1 month. By 6 months, 25.6% of intervention-group patients had reported an unplanned readmission compared with 27.9% of controls (P = .5). There were no significant differences in experience of care coordination, distress, or QOL between groups at any follow-up time point.

CONCLUSION

This trial failed to demonstrate substantial benefit of a centralized system to provide standardized, telephone follow-up for postoperative patients with colorectal cancer. Future interventions could investigate a more tailored approach.

Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction

BACKGROUND

Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear.

METHODS

A systematic review of all randomized controlled trials evaluating the effectiveness of biofeedback in adults with PFD was carried out. All online databases from 1950 to 2007 were searched. This was supplemented by hand searching references of retrieved articles.

RESULTS

Seven trials fulfilled the inclusion criteria. Three compared biofeedback with non-biofeedback treatments and four compared different biofeedback modalities. Electromyography feedback was most widely utilized. The trials were heterogeneous with varied inclusion criteria, treatment protocols and definitions of success. Most had methodological limitations. Quality of life and psychological morbidity were assessed rarely. Meta-analysis of the studies involving any form of biofeedback compared with any other treatment suggested that biofeedback conferred a sixfold increase in the odds of treatment success (odds ratio 5.861 (95 per cent confidence interval 2.175 to 15.794); random-effects model).

CONCLUSION

Although biofeedback is the recommended treatment for PFD, high-quality evidence of effectiveness is lacking. Meta-analysis of the available evidence suggests that biofeedback is the best option, but well designed trials that take into account quality of life and psychological morbidity are needed.

Oral sodium phosphate solution is a superior colonoscopy preparation to polyethylene glycol with bisacodyl

PURPOSE

The aim of this study was to compare the efficacy and patient tolerance of two bowel preparations for colonoscopy.

METHODS

Three hundred twenty-three consecutive patients undergoing colonoscopy were randomly assigned to receive either oral sodium phosphate, or 2 liters of polyethylene glycol solution preceded by the stimulant laxative bisacodyl. Patients were asked to record the effects of the preparation, noting any vomiting, nausea, or abdominal pain, and to determine a discomfort rating on a scale of 1 to 5. One hundred sixty-nine patients were assigned to the oral sodium phosphate solution, and 154 to polyethylene glycol with bisacodyl. Surgeons were blinded to the preparation used and rated the quality of the bowel preparation on a scale of 1 to 5.

RESULTS

Ninety-nine percent of patients in the sodium phosphate group drank all of the solution as opposed to 91 percent of patients in the polyethylene glycol with bisacodyl group. Patients in the sodium phosphate group reported significantly less discomfort (P = 0.002). No significant difference was reported for vomiting, nausea, or abdominal pain associated with the preparations. The quality of bowel cleansing was considered by the colonoscopists significantly better for the sodium phosphate group than the polyethylene glycol with bisacodyl group (P < 0.000001).

CONCLUSIONS

Colonoscopy preparation with sodium phosphate solution is better tolerated and more effective than polyethylene glycol with bisacodyl.

Long-term functional outcomes after laparoscopic and open rectopexy for the treatment of rectal prolapse

PURPOSE

Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there is little long-term follow-up and functional outcome data available.

METHODS

Patients who had abdominal surgery for prolapse during a ten-year period were identified and interviewed to ascertain details of prolapse recurrence, constipation, incontinence, cosmesis, and satisfaction. Additional details on recurrences that required surgery and mortality were obtained from chart review and the State Death Registry.

RESULTS

Of 321 prolapse operations, laparoscopic rectopexy was performed in 126 patients, open rectopexy in 46, and resection rectopexy in 21 patients. At a median follow-up of five years after laparoscopic rectopexy, there were five (4 percent) confirmed full-thickness recurrences that required surgery. Actuarial recurrence rates of laparoscopic rectopexy were 6.9 percent at five years (95 percent confidence interval, 0.1-13.8 percent) and 10.8 percent at ten years (95 percent confidence interval, 0.9-20.1 percent). Seven patients underwent rubber band ligation for mucosal prolapse and seven required other surgical procedures. There was one recurrence after open rectopexy (2.4 percent) and one after resection rectopexy (4.7 percent), and there was no significant difference between groups. Overall constipation scores were not increased after laparoscopic rectopexy, with no significant difference to open rectopexy or resection rectopexy.

CONCLUSIONS

This study has demonstrated that laparoscopic rectopexy has reliable long-term results for treating rectal prolapse, including low recurrence rates and no overall change in functional outcomes.

Successful overlapping anal sphincter repair: relationship to patient age, neuropathy, and colostomy formation

BACKGROUND

Fecal incontinence from single anal sphincter defects are surgically remedial and commonly the result of obstetric injuries. Overlapping anal sphincter repair has previously been associated in small series with good results in 69 to 97 percent of patients.

OBJECTIVES

The aims of this study were to assess the results of overlapping anal sphincter repair in one institution and to assess the effects of age, presence of a neuropathy, and addition of a temporary colostomy on the success of surgery.

METHODS

A study of 57 overlapping anal sphincter repairs in 56 (54 females) patients at the Royal Prince Alfred Hospital during a six-year period was performed. All patients were investigated preoperatively with endoanal ultrasound and concentric needle electromyography. Patients have been assessed prospectively since 1994 with a questionnaire, including a four-point Likert scale of continence level, the St. Mark's incontinence scoring system (range, 0-13), the Pescatori incontinence scoring system (range, 0-6), and patient assessment of success or failure of the overlapping anal sphincter repair. A colostomy was selectively formed in conjunction with an overlapping anal sphincter repair in 21 patients (8 preoperatively, 13 simultaneously), and 18 patients had a concomitant neuropathy (3 unilateral, 15 bilateral).

RESULTS

After a median follow-up of 18 months, median continence scores overall had improved from St. Mark's incontinence scoring 13 to 3 (P < 0.0001) and Pescatori incontinence scoring 6 to 2 (P < 0.0001). Forty-nine of 57 (86 percent) repairs have been successful, and 8 are considered to be failures. Twenty-one of 27 (78 percent) repairs in patients younger than 40 years of age were successful, as were 28 of 30 (93 percent) repairs in patients older than 40 years of age (P = 0.10). Four of 18 (22 percent) repairs associated with a neuropathy failed compared with 4 of 39 (10 percent) without a neuropathy (P = 0.21). Improved or normal continence was achieved in 17 of 21 (81 percent) patients with a stoma and overlapping anal sphincter repair and in 32 of 36 (89 percent) patients with an overlapping anal sphincter repair alone (P = 0.32). The presence of a stoma did not improve the rate of wound healing by primary intention (62 percent for stoma vs. 64 percent for overlapping anal sphincter repair alone; P = 0.55).

CONCLUSIONS

Single anal sphincter defects can be successfully treated with an overlapping anal sphincter repair. There is no improvement in primary healing with selective stoma formation. Age of the patient and presence of a neuropathy should not detract from proceeding with overlapping anal sphincter repair when singular anal sphincter defects are detected on endoanal ultrasound in muscle that is still active.

Workplace Bullying in Surgery

OBJECTIVE

The aim of this study was to determine the extent and nature of workplace bullying among General Surgery trainees and consultants in Australia.

DESIGN, SETTING AND PARTICIPANTS

An online questionnaire survey of General Surgery trainees and consultant surgeons in Australia was conducted between March and May 2012. Prevalence of bullying was measured using both a definition of workplace bullying and the revised Negative Acts Questionnaire (NAQ-R). Sources of bullying were also examined, as well as the barriers and outcomes of formal reporting of bullying.

RESULTS

The response rate was 34 % (370/1084) with 41 % (n = 152) of respondents being trainees. Overall, 47 % (n = 173) of respondents reported having been bullied to some degree and 68 % (n = 250) reported having witnessed bullying of surgical colleagues in the last 12 months. The prevalence of bullying was significantly higher in trainees and females, with 64 % of trainees and 57 % of females experiencing some degree of bullying. The majority of respondents (83 %) had experienced at least one negative behavior in the last 12 months, but 38 % experienced at least one negative behavior on a weekly or daily basis. The persistent negative behaviors that represent work-related bullying most commonly experienced were 'having opinions ignored' and 'being exposed to an unmanageable workload.' Consultant surgeons were the most common source of bullying for both trainees and consultants, with administration the next common source. Of those who reported being bullied, only 18 % (n = 32) made a formal complaint.

CONCLUSIONS

Despite increased awareness and interventions, workplace bullying remains a significant problem within General Surgery in Australia. The findings in this study serve as a baseline for future questionnaires to monitor the effectiveness of implemented anti-bullying interventions.

Implications of delayed diagnosis in colorectal cancer

BACKGROUND

Delayed diagnosis of colorectal cancer (CRC) continues to produce anxiety and is associated with the assumption that disease stage and survival will be worse. The aims of the present study were to assess the prevalence and reasons for delay in the diagnosis of CRC, and the effects of delay, gender, age and tumour site on the stage of disease.

METHODS

A retrospective study of 100 patients presenting with CRC during a 1-year period was performed. Delay was defined to have occurred if more than a 3-month period had lapsed from the time when initial symptoms were clearly established to the time of operation. Data were collected on principal presenting symptoms, time to first presentation to a doctor, time to diagnosis and treatment, reasons for delay, diagnostic procedures, tumour site, operation, and Australian clinicopathological (ACP) stage of the tumour.

RESULTS

Thirty-four patients had a delay in diagnosis of their cancer. In 18 patients (53%) delay was attributable to patient reasons; in 13 patients (38%) delay was attributable to doctor-related delay and in three patients (9%) it was attributable to both. Male patients were more likely to have patient-related delay (31% for male patients vs 10% for female patients; P = 0.011). Patients with delay were less likely to have a stage A tumour (6% for delay group vs 21% for non-delay group; P = 0.04). Male patients were less likely to have a stage A tumour than female patients (8% for male patients vs 25% for female patients; P = 0.018), but the effect of delay on stage disappeared when gender and tumour site were controlled in a logistic regression model.

CONCLUSIONS

The present study suggests some areas where improvements may be made concerning early diagnosis and treatment of patients with CRC.

Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion

BACKGROUND

Surgery remains the dominant treatment for large-bowel obstruction, with emerging data on self-expanding metallic stents.

OBJECTIVE

The aim of this study was to assess whether stent insertion improves quality of life and survival in comparison with surgical decompression.

DESIGN

This study reports on a randomized control trial (registry number ACTRN012606000199516).

SETTING

This study was conducted at Royal Prince Alfred Hospital, Sydney, and Western Hospital, Melbourne.

PATIENTS AND INTERVENTION

Patients with malignant incurable large-bowel obstruction were randomly assigned to surgical decompression or stent insertion.

MAIN OUTCOME MEASURES

The primary end point was differences in EuroQOL EQ-5D quality of life. Secondary end points included overall survival, 30-day mortality, stoma rates, postoperative recovery, complications, and readmissions.

RESULTS

Fifty-two patients of 58 needed to reach the calculated sample size were evaluated. Stent insertion was successful in 19 of 26 (73%) patients. The remaining 7 patients required a stoma compared with 24 of 26 (92%) surgery group patients (p < 0.001). There were no stent-related perforations or deaths. The surgery group had significantly reduced quality of life compared with the stent group from baseline to 1 and 2 weeks (p = 0.001 and p = 0.012), and from baseline to 12 months (p = 0.01) in favor of the stent group, whereas both reported reduced quality of life. The stent group had an 8% 30-day mortality compared with 15% for the surgery group (p = 0.668). Median survival was 5.2 and 5.5 months for the groups (p = 0.613). The stent group had significantly reduced procedure time (p = 0.014), postprocedure stay (p = 0.027), days nothing by mouth (p = 0.002), and days before free access to solids (p = 0.022).

LIMITATIONS

This study was limited by the lack of an EQ-5D Australian-based population set.

CONCLUSIONS

Stent use in patients with incurable large-bowel obstruction has a number of advantages with faster return to diet, decreased stoma rates, reduced postprocedure stay, and some quality-of-life benefits.

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

Single-incision laparoscopic right hemicolectomy

BACKGROUND

The results of a prospective consecutive series of single-incision laparoscopic right hemicolectomy procedures are presented.

METHODS

Right colonic resections were performed by a single-incision laparoscopic technique between February and December 2009. Surgical outcomes were recorded in a prospective database.

RESULTS

Twenty-two consecutive procedures were completed by single-incision laparoscopic colorectal surgical resection. All patients were alive at 30 days. The median length of hospital stay was 5 days. Morbidity was encountered in six patients. Pathological examination of the resected specimen showed adenocarcinoma in 13 patients, adenoma in five, carcinoid in two, Crohn's disease in one patient and an intussuscepting lipoma in one. Clearance from the pathology was greater than 5 cm in all cases and the median lymph node harvest in patients with cancer was 17 (range 10-30).

CONCLUSION

Single-incision laparoscopic surgery is a possible approach to right colonic resection with potential for minimal access advantages.

Definitive surgical closure of enterocutaneous fistula: outcome and factors predictive of increased postoperative morbidity

AIM

Enterocutaneous fistula (ECF) presents a complex management problem with significant mortality and morbidity. The aim of this study was to assess the outcome of patients undergoing surgical cure for ECF and to predict factors that might relate to increased postoperative morbidity.

METHOD

Medical records of all patients who underwent definitive surgery for cure of an ECF within our colorectal surgery unit between 2000 and 2010 were reviewed.

RESULTS

Forty-one patients (18 male) were identified, in whom 44 definitive procedures were performed. The median age was 54 (17-81) years. The median postoperative length of stay in hospital was 14 (2-213) days. Half (50%) of the ECFs occurred as a postoperative complication followed by spontaneous fistulation in Crohn's disease (36%). The interval to definitive surgery was influenced by the aetiology of the fistula. The median time to surgery after formation of postoperative fistula was 240 days (7.9 months). There was no 30-day postoperative mortality. There were two (4.5%) recurrences at 3 months. Thirty-eight (86%) patients suffered postoperative morbidity as defined by the Clavien-Dindo classification. High-grade morbidity occurred in 32% of patients. On univariate analysis, factors identified as being significantly associated with high-grade morbidity included a fistula output of > 500 ml/day (P = 0.004) in patients with postoperative ECF, malnutrition at presentation (P = 0.04) and a serum albumin value of < 30 g/l (P = 0.02) in patients with spontaneous ECF due to Crohn's disease.

CONCLUSION

The majority of persistent complex ECFs can be cured surgically with low mortality and recurrence in a multidisciplinary setting. Postoperative morbidity, however, remains a significant burden.

Defunctioning of the anorectum: historical controlled study of laparoscopic vs. open procedures

BACKGROUND

Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy.

OBJECTIVES

The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group.

METHODS

Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented.

RESULTS

Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7 vs. 89.9 mg; P < 0.01), an earlier tolerance of both liquid (mean, 2.1 vs. 3.7 days; P < 0.01) and solid diets (mean, 3.6 vs. 5.5 days; P < 0.001), and an earlier time to passage of both flatus (mean, 2.2 vs. 3.6 days; P < 0.001) and feces (mean, 3.7 vs. 5.6 days; P < 0.001). Operating time was longer for the laparoscopic group (mean, 176 vs. 104 minutes; P < 0.001), whereas median time to discharge from hospital was shorter (median, 8 vs. 11 days; P = 0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients.

CONCLUSIONS

In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.

Karydakis flap repair for sacrococcygeal pilonidal sinus disease: how important is technique?

Numerous operative and conservative treatments have been described in the published work for the management of sacrococcygeal pilonidal sinus; yet there remains considerable debate over its ideal treatment. This report is an audit of our results using the Karydakis flap repair in the management of this condition. We analysed prospective data on 70 patients who had had a Karydakis procedure. The length of follow up ranged from 1 to 79 months (median 36 months). Seventy-one operations were carried out in 70 patients. This included 12 patients (17%) who had previously undergone between one and four procedures (median 2) for recurrent disease. Superficial wound breakdown occurred in 27 patients (38%) and complete wound breakdown occurred in six patients (8.4%). These wounds were allowed to heal by secondary intent. The median time to complete healing for superficial and complete wound breakdown was 80 and 84 days, respectively. Disease recurrence occurred in three patients (4.2%) -- two of whom had recurrent disease at the time of this presentation. Of the three patients who had a recurrence after our surgery, two had a superficial breakdown and one had a complete wound breakdown. Sacrococcygeal pilonidal disease has a low recurrence rate when treated by the Karydakis operation involving flattening of the midline cleft. This procedure avoids the need for more complicated flap repairs.

The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review

BACKGROUND

The difficulty of performing total mesorectal excision (TME) for rectal cancer partly relies on the surgeon's subjective assessment of the individual patient's pelvic anatomy and tumour characteristics, which generally influences the choice of platform used (open, laparoscopic, robotic or trans-anal surgery). Recent studies have found associations between several anatomical pelvic measurements and surgical difficulty. The aim of this study was to systematically review existing data reporting the use of magnetic resonance imaging (MRI)-based pelvic measurements to predict technical difficulty and outcomes of TME, and determine whether pelvimetry could optimise patient-specific selection of a particular surgical approach.

METHODS

MEDLINE, Embase and Cochrane Library databases were systematically searched for studies reporting MRI-based pelvic measurements in patients undergoing surgery for rectal cancer, and the effect of these measurements on surgical difficulty.

RESULTS

Eleven studies reporting the association between MRI-pelvimetry measurements and rectal cancer surgical outcomes were included. Indicators for surgical difficulty used in the included studies were involved circumferential resection margin, longer operative time, incomplete TME, higher blood loss, anastomotic leak, conversion to open surgery and overall complications. Bony pelvic measurements which were associated with increased surgical difficulty in more than one study were a smaller interspinous distance, a smaller intertubercle distance, a smaller pelvic inlet and larger pubic tubercle height. Two studies identified larger mesorectal fat area as a predictor of surgical difficulty.

CONCLUSIONS

Bony pelvic measurements may predict surgical difficulty during TME, however, use of different indicators of difficulty limit comparison between studies. Early data suggest MRI soft tissue measurements may predict surgical difficulty and warrants further investigation.

Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence after colorectal surgery: a meta-analysis

BACKGROUND

Enhanced recovery after surgery protocols supports the post-operative use of nonsteroidal anti-inflammatory drugs (NSAIDs) to minimize the use of opioids. However, there is an increasing concern on the impaired wound healing of anastomosis associated with NSAID use, potentially causing a higher risk of anastomotic leakage. The aim was to conduct a meta-analysis to evaluate the association of NSAIDs with anastomotic leakage after colorectal surgery.

METHODS

A literature search was conducted using the MEDLINE, PubMed, Cochrane Library and Clinicaltrial.gov. Studies identified were appraised with standard selection criteria. Data points were extracted and meta-analysis was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Seventeen studies comprising of 26 098 patients were examined. The analysis of all studies showed a significantly lower rate of anastomotic dehiscence in the no-NSAID group (pooled odds ratio (OR) = 2.00, 95% confidence interval (CI) = 1.48-2.71, P < 0.00001). The analysis of randomized controlled trials (RCTs) demonstrates similar dehiscence rates between both groups (P = 0.17). In subgroup analysis, non-selective NSAIDs was associated with a higher risk of anastomotic dehiscence (pooled OR = 2.02, 95% CI = 1.62-2.50, P < 0.00001). However, there was no difference in the incidence of anastomotic leakage between no-NSAID group and selective NSAID group (P = 0.05).

CONCLUSION

Use of NSAIDs after colorectal surgery may be associated with a higher risk of anastomotic leakage. It is important to balance between the benefits of faster post-operative recovery and potential adverse effects of NSAIDs. Selective NSAIDs may be safer than non-selective ones. More RCTs are warranted to further evaluate the relationship between anastomotic leakage and use of NSAIDs, especially selective ones.

Major Abdominal and Perianal Surgery in Crohn's Disease: Long-term Follow-up of Australian Patients With Crohn's Disease

BACKGROUND

Most patients with Crohn's disease still require surgery despite significant advances in medical therapy, surveillance, and management strategies.

OBJECTIVE

The purpose of this study was to assess surgical strategies and outcomes in Crohn's disease, including surgical recurrence and emergency surgery.

DESIGN

This was a multicenter, retrospective review of a prospectively collected database.

SETTINGS

A specialist-referred cohort of patients with Crohn's disease between 1970 and 2009 was studied.

PATIENTS

Included were 972 patients with Crohn's disease who were referred to the Sydney Inflammatory Bowel Disease cohort database.

MAIN OUTCOME MEASURES

Main outcomes of interest were the rates of major abdominal and perianal surgery between decades (1970-1979, 1980-1989, 1990-1999, and 2000-2009), indications for surgery, types of procedure performed, rate of elective and emergency surgery, risk of surgical recurrence, and predictive factors for surgery.

RESULTS

Between 1970 and 2009, the overall risks of surgery within 5, 10, and 15 years of diagnosis were 31.7%, 43.3%, and 48.4%. The median time to first surgery from time of diagnosis was 2 years (range, 0-31 years). A total of 6.7% of patients required emergency surgery within 5 years of diagnosis. In total, 8.8% of patients required emergency surgery within 15 years. The overall risk of surgical recurrence was 35.9%. The risk of major abdominal surgery significantly decreased between 2000 and 2009 when compared with the 1970 to 1979 period (OR = 0.49 (95% CI, 0.34-0.70). However, the rate of perianal surgery significantly increased (OR = 5.76 (95% CI, 2.54-13.06)). The main indications for surgery were enteric stricture or obstruction, perianal disease, and intra-abdominal fistulas/abscess. Of the 972 patients over 4 decades, only 11 patients (1.1%) were diagnosed with colorectal cancer.

LIMITATIONS

This was a specialist-referred cohort, not a population-based study.

CONCLUSIONS

The rate of major abdominal surgery has decreased, with surgery reserved for more severe and complicated disease. The natural history of patients with more complicated Crohn's disease and severe phenotypes puts them at higher risk of surgical recurrence and emergency surgery. There has been no reduction in emergency surgery rates and there has been an increase in surgical recurrence despite the reduction in surgical rate morbidity. See Video Abstract at http://links.lww.com/DCR/A483.

Management of large bowel obstruction in advanced ovarian cancer with intraluminal stents

BACKGROUND

While most patients with advanced ovarian cancer can achieve prolonged remission with surgery and chemotherapy, eventually most will recur. Commonly bowel obstruction will complicate their recurrence, usually heralding the terminal phase of their disease. Standard management of bowel obstruction has involved surgical intervention after a period of conservative medical management. Unfortunately, many patients submitted for surgery do not derive benefit from such an approach, spending the majority of their remaining life in the hospital or recovering from the surgery.

CASES

Two cases of patients with large bowel obstruction resulting from advanced and recurrent ovarian cancer are presented. In the first case, a rectal stent was decided upon as the appropriate management as she was failing first-line therapy, with little likelihood of recovering from a laparotomy. In the second case a large recurrent infected tumor mass had already been debulked, but was continuing to cause obstructive symptoms. In both cases immediate relief of their gastrointestinal symptoms was achieved.

CONCLUSIONS

In patients with large bowel obstruction secondary to extrinsic compression, useful palliation can be achieved with a colonoscopically placed endoluminal stent.

Discrimination, Bullying and Harassment in Surgery: A Systematic Review and Meta-analysis

BACKGROUND

In 2015, the public media in Australia reported a series of life stories of victims who had been subjected to inappropriate behaviors in their surgical careers, bringing the profession into disrepute. Currently, limited data are available in the medical literature on discrimination, bullying and harassment (DBH) in surgery. This significant information gap prompted a systematic review to compile relevant information about DBH in surgical practice and training, in particular, its prevalence and impact.

METHODS

A literature search was conducted using the MEDLINE, EMBASE and PubMed databases (May 1929-October 2017). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Eight studies, comprising 5934 participants, were examined. Discrimination occurred in a pooled estimate of 22.4% [95% Confidence Interval (CI) = 14.0-33.9%]. One of the papers reported the prevalence of bullying using two methods including Revised Negative Acts Questionnaire and a definition by Einarsen. Pooled estimate of incidence rate was thus 37.7% (95% CI = 34.0-41.5%) and 40.3% (95% CI = 34.7-46.2%), respectively. In terms of harassment, pooled prevalence was 31.2% (95% CI = 10.0-65.0%).

CONCLUSIONS

DBH is a significant issue in surgery. The true incidence of these issues may remain underestimated. Actions are being taken by professional bodies to create a positive culture in surgery. The effectiveness of these strategies is yet to be determined. More studies are warranted to investigate the magnitude of these issues given their psychological impact, and more importantly to monitor the effectiveness of current measures.

Evolution of the pelvic pouch procedure at one institution: the first 100 cases

BACKGROUND

Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series.

METHODS

Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation.

RESULTS

After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis.

CONCLUSIONS

Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.

Predictors for complete pathological response for stage II and III rectal cancer following neoadjuvant therapy - A systematic review and meta-analysis

BACKGROUND

There has been an increasing interest in the complete pathological response (pCR) in rectal cancers following neoadjuvant therapy. The aim of this study was to identify predictive factors of pCR in locally advanced rectal cancer following neoadjuvant therapy.

METHODS

The studies identified were appraised with standard selection criteria. The selection criteria included studies on patients with stage II or III rectal cancer who underwent neoadjuvant therapy.

RESULTS

Patients with pCR are more likely to be older (p = 0.0002), have cancers closer distance to the anal verge (p < 0.00001), smaller tumors (P < 0.0001), no clinical lymph nodes involvement (p=<0.00001) and waited more than eight weeks until definitive surgery (p = 0.002). There was no difference in gender (p = 0.15) and tumor differentiation (p = 0.21).

CONCLUSIONS

The 'Watch and Wait' approach may be appropriate for selected patients. Patients with lower rectal cancers, smaller tumors, and negative clinical lymph node involvement may be more likely to achieve pCR following neoadjuvant therapy.

Ileal pouch-anal anastomosis: the Australasian experience

OBJECTIVE

The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia.

METHOD

The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results.

RESULTS

Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005).

CONCLUSION

A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.

Recurrence and cancer-specific death after adjuvant chemotherapy for Stage III colon cancer

AIM

The recommended standard of care for patients after resection of Stage III colon cancer is adjuvant 5-fluorouracil based chemotherapy - FOLFOX (fluorouracil, leucovorin with oxaliplatin) - or CAPOX (capecitabine, oxaliplatin). This may be modified in older patients or depending on comorbidity. This has been challenged recently as the apparent benefit of adjuvant chemotherapy may arise from improvements in surgery or preoperative imaging or pathology staging. This study compares recurrence and colon-cancer-specific death between patients who received postoperative adjuvant chemotherapy and those who did not.

METHOD

Prospectively recorded data from 363 consecutive patients who had a resection for Stage III colonic adenocarcinoma between 1995 and 2010 inclusive were analysed. Surviving patients were followed for at least 5 years. The suitability of patients for chemotherapy was discussed routinely at multidisciplinary team meetings. The incidence of recurrence and colon-cancer-specific death was evaluated by competing risk methods.

RESULTS

After adjustment for the competing risk of non-colorectal cancer death, there was no significant difference in recurrence between the 204 patients who received chemotherapy and the 159 who did not [hazard ratio (HR) 0.94, 95% CI 0.66-1.32, P = 0.700) and no significant difference in colon-cancer-specific death (HR 0.73, 95% CI 0.50-1.04, P = 0.084; HR 0.88, 95% CI 0.57-1.36, P = 0.577 after adjustment for relevant covariates).

CONCLUSION

These findings question the routine use of chemotherapy after complete mesocolic excision for Stage III colon cancer. Recurrence and cancer-specific death, assessed by competing risk methods, should be the standard outcomes for evaluating the effectiveness of adjuvant chemotherapy after potentially curative resection.

Implementing entrustable professional activities: the yellow brick road towards competency-based training?

BACKGROUND

We describe implementation of competency-based postgraduate surgical training, using an entrustable professional activities (EPAs) programme. The programme aims to improve patient outcomes by optimizing supervision of surgical trainees, creating opportunities for additional teaching and feedback. The curriculum was designed to maximize feasibility for implementation within a colorectal surgical department.

METHODS

The curriculum was developed using previously described methods by consensus between two consultants within the department. Seven EPAs were identified and described for each grade of trainee. A consultant within the teaching faculty or a delegate is required to assess each EPA and provide formal feedback until the trainee is given permission to act autonomously.

RESULTS

It is hoped the programme can progress with minimal disruption to key stakeholders. We will record trainee assessment data anticipating that performance of trainees on other tasks in the future may provide some evidence of validity for the EPA assessments.

CONCLUSIONS

There are perceived benefits and problems evident in the EPA model at this early stage of implementation. The programme should result in an increase in the number of formative assessments and feedback opportunities for trainees. The assessment process is familiar to supervisors, which should facilitate implementation of the curriculum. There is concern that supervisors may require further training to ensure the assessment process is objective and reproducible. The EPA programme could make the process of delegating patient care to trainees more transparent, but we have not identified a method of widely disseminating trainee assessment data without the potential to prejudice trainees unfairly.