Scoring the quality of total mesorectal excision for the prediction of cancer-specific outcome

AIM

A three-grade system for macroscopic evaluation of the resection plane is used to describe the quality of total mesorectal excision (TME). In several studies, two of the three grades have been combined when analysing the outcome. The aim of our study was to compare the predictive value of the three-graded with that of a two-graded TME score.

METHOD

The quality of TME in 1382 patients who underwent elective resection for mid or low rectal adenocarcinoma was registered by 65 hospitals in PROCARE, a Belgian multidisciplinary improvement project. Prediction of outcome based on the classic three-grade score was compared with a two-grade scoring system in which intramesorectal resection (IMR) was combined with mesorectal (MRR) or with muscularis propria resection (MPR). End-points included the local recurrence rate, distant metastasis rate (DMR), disease-free survival (DFS) and overall survival (OS).

RESULTS

Among the 1382 resections, 63% were MRR, 27% IMR and 9% MPR. No significant differences were found in local recurrence between the different grades of TME. A two-grade score distinguishing MRR from the others was found to predict DMR, DFS and OS as well as the three-grade score.

CONCLUSION

The discriminatory and predictive value of a two-grade score, differentiating MRR from the combined IMR and MPR, was as good as the classic three-grade score.

Long head of biceps femoris flap in anal fistula treatment: anatomical study and case report

In case of complex anal fistulae, the treatment can include muscular flaps. The gracilis transposition flap is the gold-standard in perineal reconstructive surgery, with wide use during the past decades. However, in some cases, this flap is too short to reach difficult locations such as the posterior perineum. The long head of the biceps femoris, which has already been studied in the electrically stimulated neosphincter formation, could be more appropriate in such clinical situations. Furthermore, its potential advantages, amongst which an excellent functional outcome, would be to allow persistent prone position, during both treatment and reconstruction, as well as a more favorable intramuscular vascularisation. We report the case of a 39-year-old man with a complex recurrent transphincteric posterior anal fistula with an external orifice in the right buttock and complicated with a severe cellulitis, treated with an endo-anal flap combined with a long head of biceps femoris pediculised flap.

Correlations between technical skills and behavioral skills in simulated neonatal resuscitations

OBJECTIVE

Neonatal resuscitation requires both technical and behavioral skills. Key behavioral skills in neonatal resuscitation have been identified by the Neonatal Resuscitation Program. Correlations and interactions between technical skills and behavioral skills in neonatal resuscitation were investigated.

STUDY DESIGN

Behavioral skills were evaluated via blinded video review of 45 simulated neonatal resuscitations using a validated assessment tool. These were statistically correlated with previously obtained technical skill performance data.

RESULT

Technical skills and behavioral skills were strongly correlated (ρ=0.48; P=0.001). The strongest correlations were seen in distribution of workload (ρ=0.60; P=0.01), utilization of information (ρ=0.55; P=0.03) and utilization of resources (ρ=0.61; P=0.01). Teams with superior behavioral skills also demonstrated superior technical skills, and vice versa.

CONCLUSION

Technical and behavioral skills were highly correlated during simulated neonatal resuscitations. Individual behavioral skill correlations are likely dependent on both intrinsic and extrinsic factors.

Effect of hospital volume on quality of care and outcome after rectal cancer surgery

BACKGROUND

Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited.

METHODS

Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data.

RESULTS

A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II-III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population.

CONCLUSION

Some volume effects were observed, but their effect size was limited.

Back to basics: iatrogenic intravenous cannula embolus

We present a case of distal venous embolisation of a peripheral intravenous cannula tip that had lost its structural integrity through repeated failed attempts of insertion of the same cannula, contrary to protocols for intravenous access. Radiological imaging confirmed the presence of a foreign body in the middle finger and the patient was brought to theatre. A 2.2cm long catheter tube was removed via a venotomy from the dorsal digital vein.

Exploring mesoscopic physics of vacancy-ordered systems through atomic scale observations of topological defects

Vacancy-ordered transition metal oxides have multiple similarities to classical ferroic systems including ferroelectrics and ferroelastics. The expansion coefficients for corresponding Ginzburg-Landau-type free energies are readily accessible from bulk phase diagrams. Here, we demonstrate that the gradient and interfacial terms can quantitatively be determined from the atomically resolved scanning transmission electron microscopy data of the topological defects and interfaces in model lanthanum-strontium cobaltite. With this knowledge, the interplay between ordering, chemical composition, and mechanical effects at domain walls, interfaces and structural defects can be analyzed.

Lack of folate improvement in high risk indigenous Australian adults over an average of 6.5 years: a cohort study

Socioeconomically vulnerable groups in developed countries suffer excess chronic disease due in large part to an energy dense but nutrient poor diet. Low folate can be a marker of poor dietary quality and is also affected by smoking and chronic alcohol intake, all of which cluster in groups with a low socioeconomic position. A 4.5 to 9 year follow-up study of 567 indigenous adults from remote communities in far north Queensland, Australia, from 1998 to 2007 was conducted. Analysis of the effects of demographic factors, smoking, risky alcohol drinking, fruit and vegetable intake and waist circumference on changes in red cell folate (RCF) status was conducted. Prevalence of low red cell folate doubled in the cohort from a high baseline over this seven year period: 36.9% deficient in 2007, 15.9% at baseline (p<0.001). Smoking was associated with lower folate levels. People with a normal RCF were less likely to be smokers, and were more likely to have a greater number of serves of vegetables (RR 1.06, 95% CI 1.02-1.10) than those who were deficient at follow-up. The introduction of voluntary folate fortification since 1995 does not appear to have impacted on the already poor folate status of this cohort of adults. The increased prevalence of low folate has occurred despite improvements in the food supply, indicating the need for nutrition promotion, and subsidies for healthy food in remote communities. The impact of mandatory folate fortification of flour since 2009 should be assessed in this high risk population.

Different surgical strategies in the treatment of familial adenomatous polyposis: what's the role of the ileal pouch-anal anastomosis?

BACKGROUND AND STUDY AIMS

Restorative coloproctectomy (RCP) with ileal pouch-anal anastomosis (IPAA), is one of the surgical responses to the crucial question of prophylactic treatment in familial adenomatous polyposis (FAP). No consensus has been reached, until now, to choose between IPAA and ileo-rectal anastomosis (IRA), the rectal sparing prophylactic colectomy. This paper aims to review the latest issues related to IPAA and highlights its specificities compared to IRA.

METHODS

PubMed database was searched using the following search items: familial adenomatous polyposis, surgery, ileal pouch-anal anastomosis, ileo-rectal anastomosis. Papers published between 1978 and 2010 were selected.

RESULTS

Absence of mortality, acceptable morbidity and good functional results combined to high quality of life have promoted the IPAA technique. New technical issues such as the double stapled technique, mesenteric lengthening, omission of temporary protective stoma can be addressed almost systematically for these patients. A laparoscopic approach, lessening the body image impact, has proven to be as effective and safe as the open approach to perform IPAA. Further advantages of laparoscopic IPAA rely on the lower adhesion formation resulting in less small bowel occlusion. Sexuality, fertility and childbirth are important functional issues often cited as threatened by the pelvic manoeuvres of the IPAA technique which can be prevented by close rectal wall dissection and a laparoscopic approach.

CONCLUSION

IPAA offers the best available prophylaxis in FAP patients. Technical enhancements in IPAA will most probably decrease the functional risks. Thus IPAA remains the alternative to IRA for the prophylactic treatment of FAP.Nevertheless, based on the latest evidence, the choice between both procedures is still matter of debate.