Cost Analysis of Pelvic Exenteration Surgery for Advanced Pelvic Malignancy

BACKGROUND

Pelvic exenteration (PE) is a radical procedure involving multi-visceral resection for locally advanced pelvic malignancies. Such radical surgery is associated with prolonged operating theater time and hospital stay, as well as a substantial risk of postoperative complications, and therefore significant financial cost. This study aimed to comprehensively detail the inpatient cost of PE at a specialist center in the Australian public sector.

METHODS

A retrospective costing review of consecutive PE operations at Royal Prince Alfred Hospital in Sydney between March 2014 and June 2022 was performed. Clinical data were extracted from a prospectively maintained database, and in-hospital costing data were provided by the hospital Performance Unit. All statistical analyses were performed using SPSS.

RESULTS

Pelvic exenteration was performed for 461 patients, of whom 283 (61 %) had primary or recurrent rectal cancer, 160 (35 %) had primary or recurrent non-rectal cancer, and 18 (4 %) had a benign indication. The median admission cost was $108,259.4 ($86,620.8-$144,429.3) (Australian dollars [AUD]), with the highest costs for staffing followed by the operating room. Overall, admission costs were higher for complete PE (p < 0.001), PE combined with cytoreductive surgery (CRS) (p < 0.001), and older patients (p = 0.006).

DISCUSSION

The total admission cost for patients undergoing PE reflects the complexity of the procedure and the multidisciplinary requirement. Patients of advanced age undergoing complete PE and PE combined with CRS incurred greater costs, but the requirement of a sacrectomy, vertical rectus abdominal flap reconstruction, major nerve or vascular excision, or repair were not associated with higher overall cost in the multivariate analysis.

Caught Between Stewardship and Resistance: How to Treat Acute Complicated Diverticulitis in Areas of Low Antimicrobial Susceptibility?

Antimicrobial resistance is one of the main threats to public health, with multidrug-resistant (MDR) pathogens on the rise across continents. Although treatment guidelines generally recommend antimicrobial therapy for acute complicated diverticulitis, they do not specify treatment pathways according to local or national resistance profiles. There is sparse data regarding specific pathogens involved in Hinchey II-IV patients who undergo surgery. This study seeks to address these issues and determine how often and what types of MDR bacteria occur in patients undergoing emergency surgery. We prospectively enrolled patients admitted between 2020-2023 and who underwent emergency surgery for complicated acute diverticulitis. We analysed the inflammatory response parameters at admission, the type of surgery employed for source control, identified pathogens in the peritoneal samples, their antimicrobial susceptibility, the efficacy of antimicrobial empiric therapy, and mortality. Gram-negative bacteria were identified most often, with Escherichia coli being mostly MDR (43.9%) or extended-spectrum beta-lactamase producing (ESBL +ve) (24.4%), while most strains of Klebsiella pneumoniae were extended-spectrum beta-lactamase positive (ESBL +ve) (80%) and MDR (80%). Of the Enterococcus spp., 57.14% were vancomycin-resistant (VRE) strains. Patients with Hinchey III/IV were significantly more associated with MDR. Patients with multiple pathogens were significantly associated with ESBL+/VRE strains. Age, leucocytosis, and procalcitonin levels at admission were good indicators for mortality prediction, which occurred in four cases. In an age when antibiotic stewardship is advisable especially in emergency settings, the treatment should be tailored according to local profiles of MDR to ensure adequate outcomes for patients.

Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.

Low Rates of Short-Term Anastomotic Complications After Kono-S versus Side-to-Side Stapled Anastomosis

INTRODUCTION

The Kono-S (KS) anastomosis for Crohn's disease (CD) is associated with improved endoscopic and clinical long-term outcomes. Ileocolonic anastomoses in CD are associated with an unacceptable anastomotic complication rate - up to 40%. Investigation of short-term benefits of KS is thus warranted. Here, we evaluate 90-d postoperative complications following KS versus side-to-side stapled anastomosis in patients with CD.

METHODS

This is a retrospective case-control conducted at our tertiary medical center; data retrieved are from cases between January 2019 and May 2023. Thirty-eight consecutive patients with CD who underwent KS were matched with 38 patients who underwent side-to-side stapled anastomosis. Patients were initially age and sex matched; then, characteristics including body mass index, American Society of Anesthesiologists class, and disease severity indicated by inpatient status, preoperative laboratory values, steroid and disease modifying drug use were compared between cases and controls, using chi square, t-test, or Mann-Whitney U test.

RESULTS

Cohorts did not differ in the aforementioned characteristics with the exception of higher preoperative erythrocyte sedimentation rate in the KS group. There was no difference in operative approach, or complications between groups; one patient undergoing KS required return to operating room for fascial dehiscence, while two in the side-to-side stapled group required return to operating room for anastomotic complications. KS operative times were significantly longer.

CONCLUSIONS

KS is associated with an acceptable rate of short-term complications. In our matched series of 38 patients, we had no anastomotic leaks or bleeds in our KS group. Adoption of this technique may provide immediate postoperative benefits in addition to long-term disease reduction.

Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair

BACKGROUND

Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI after abdominal surgery is from the gastrointestinal and urological literature. These data have been extrapolated to vascular surgery, especially with regard to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.

METHODS

This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone nonelective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.

RESULTS

A total of 123 patients met study criteria with an overall POI rate of 8.9% (n = 11). Patients who developed a POI had a significantly lower body mass index (24.3 kg/m2 vs 27.1 kg/m2; P = .003), were more likely to undergo a transperitoneal approach (81.8% vs 42.0%; P = .022), midline laparotomy (81.8% vs 37.5%; P = .008), longer total clamp times (151.6 minutes vs 97.7 minutes; P = .018), greater amounts of intraoperative crystalloid infusion (3495 mL vs 2628 mL; P = .029), and were more likely to return to the operating room (27.3% vs 3.6%; P = .016). Proximal clamp site was not associated with POI (P=.463). Patients with POI also had higher rates of postoperative vasopressor use (100% vs 61.1%; P = .014) and greater amounts of oral morphine equivalents in the first 3 postoperative days (488.0 ± 216.0 mg vs 203.8 ± 29.6 mg; P = .016). Patients who developed POI had longer lengths of stay (12.5 days vs 7.6 days; P < .001), a longer duration of nasogastric tube decompression (5.9 days vs 2.2 days; P < .001), and a longer period of time before diet tolerance (9.1 days vs 3.7 days; P < .001). Of those who developed a POI (n = 11), four (36.4%) required total parental nutrition during the admission.

CONCLUSIONS

POI is a morbid complication among patients undergoing elective open AAA surgery that prolongs hospital stay. Patients at risk for developing a POI are those with a lower body mass index, as well as those who had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, postoperative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important perioperative opportunities to decrease the prevalence of POI.

Botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure: a meta-analysis of randomized control trials

BACKGROUND

Anal fissures, tears in the epithelium of the anal canal that cause pain and bleeding, have a lifetime prevalence of 11%. While surgical treatments, such as lateral internal sphincterotomy are traditional, they pose postoperative complications. Recent studies investigated less invasive options involving botulinum toxin injection, showing promise with fewer adverse effects. The aim of this study is to compare the outcomes of botulinum toxin injection to lateral internal sphincterotomy for chronic anal fissures.

METHOD

Up to October 2023, an extensive literature search was conducted in PubMed, Scopus, and Google Scholar to identify relevant papers. This systematic review and meta-analysis examined the comparative effectiveness of lateral internal sphincterotomy and botulinum toxin injection in the treatment of chronic anal fissures. The methodology adheres to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, and the study protocol has been registered with the Open Science Framework (OSF).

RESULTS

A total of 1,839 patients from 18 trials were included in the meta-analysis. Patients undergoing lateral internal sphincterotomy had higher healing compared to botulinum toxin injection (pooled effect = 0.77; 95% CI= [0.69- 0.83]; I2 = 90.95%; P = 0.00).

CONCLUSION

Our study revealed the efficacy of lateral internal sphincterotomy over botulinum toxin injection in promoting healing for chronic anal fissures. These findings emphasize the clinical advantage of traditional surgical interventions in the management of this condition. However, further studies with long-term follow-up are required to confirm our observations.

A UK wide survey of general surgeons' experience of the primary repair of obstetric anal sphincter injuries

AIM

Obstetric anal sphincter injuries (OASIs) are associated with devastating consequences, mainly faecal incontinence. A timely and correct repair is necessary to reduce the risk of maternal morbidity. The aim was to explore the experience and practice of on-call general surgeons in the acute repair of OASIs.

METHOD

A cross-sectional, observational questionnaire study was performed. Registrars and consultants participating in an emergency general surgical rota in the UK were included. A 33-item questionnaire was disseminated over a 9-month period from April 2023. A descriptive, thematic analysis of the data was undertaken.

RESULTS

In all, 310 responses were analysed. 42.3% of colorectal respondents (of which 29% were pelvic floor specialists), 24.3% of general surgeons, 16.7% of hepato-biliary surgeons and 13.7% of upper gastrointestinal surgeons were contacted to assist with an acute repair. Of those contacted, 52.3% typically assisted with a 3C or 4 tear, 54.2% received no training and 95.5% performed less than three acute repairs in the previous year. 57.6% of all respondents were not confident at all in the repair of these injuries, 55% highlighted a lack of experience and 36% mentioned a curricular gap.

CONCLUSION

Surgeons may be called to assist with an acute OASI repair, particularly in cases of severe anatomical disruption. This occurs infrequently. There is a lack of consensus as to who is responsible for these injuries. Obstetricians have structured training in both the recognition and repair of these injuries. This paper serves to highlight the lack of training for surgeons who report doing this surgery despite lacking the required competences.

Danish guidelines for treating acute colonic obstruction caused by colorectal cancer-a review

Acute onset of colonic obstruction caused by colorectal cancer occurs in approximately 14% of Danish patients with colon cancer(1). Given that colorectal cancer is a common cancer with about 4,500 new cases annually, acute onset will occur in a reasonably large number of patients in Danish emergency departments, and all surgeons should be familiar with the treatment principles. A revised guideline from the Danish Colorectal Cancer Group is currently underway, and this status article reviews the latest knowledge and recommendations.

A comprehensive review and update on acute severe lower gastrointestinal bleeding in Crohn's disease: a management algorithm

Acute severe lower gastrointestinal bleeding is a rare but potentially fatal complication of Crohn's disease (CD), affecting between 0.6% and 5.5% of CD patients during their lifelong disease course. Managing bleeding episodes effectively hinges on vital resuscitation. Endoscopic evaluation and computed tomography play crucial roles in accurate identification and intervention. Fortunately, most bleeding episodes can be successfully managed through appropriate conservative treatment. Medical therapies, particularly infliximab, aim to induce and maintain mucosal healing and serve as the leading treatment approach. Minimally invasive procedures, such as endoscopic hemostasis and angio-embolization, can achieve immediate hemostasis. Surgical treatment is only considered a last resort when conservative therapies fail. Despite achieving hemostasis, the risk of rebleeding ranges from 19.0% to 50.5%. The objective of this review is to provide a comprehensive and updated overview of the clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic outcomes associated with acute severe gastrointestinal bleeding in CD. Furthermore, we aimed to propose a management algorithm to assist clinicians in the effective management of this condition.

Management of haemorrhoids through siddha formulation Kuppaimeni Samoola

Hemorrhoids are a very common anorectal condition characterized by symptomatic enlargement and distal dislodgment of anal cushions which mainly affects the quality of life. Siddha herbal medicine Kuppaimeni (Acalypha Indica) is indicated for haemorrhoids, was used in this pilot study to catalogue the feasibility of Kuppaimeni samoola choornam in the management of first, second, and third- degree internal Hemorrhoids, along with a dietary regimen, of including two fig fruits in the daily diet. Ten participants were selected for the study and they underwent medication with a drug administration calendar period of forty - eight days. Prognosis was assessed by using Hemorrhoids Symptoms Severity (HSS) Scoring. The study findings of KSC are: among the ten cases, eight subjects got complete relief from symptoms after 48 days of medication. HSS scoring reduced to zero for all (8) first and second degree hemorrhoid cases and these 8 cases never had repeated episodes in follow-up time (5 years of follow-up after withdrawing medication). This study suggests the feasibility of using KSC in treating first and second-degree internal hemorrhoids.

Electromyographic parameters for treatment of pelvic floor disorders in pregnant and postpartum women: A review protocol

Electromyography is a widely used instrument in clinical practice to evaluate and treat pelvic floor disorders in pregnant and postpartum women. The objective of this study is to analyze the scientific evidence on the electromyography parameters used for treatment of pelvic floor disorders in pregnant women in any gestational week and postpartum women up to 12 months after delivery. A systematic review of randomized controlled experimental studies (clinical trials) and quasi-experimental studies in English, Portuguese or Spanish, which used electromyography as an intervention for treatment of pelvic floor disorders in pregnant or postpartum women up to 12 months after delivery will be performed in online databases (Scopus, Medline, Pedro, Scielo and Pubmed),. Risk of bias assessment will be performed using Cochrane group tools. The Rob 2.0 tool will be used for experimental studies and the Robins-I tool for non-experimental studies. The protocol was registered in PROSPERO (no.433510). The quality of the evidence will be analyzed using the GRADE System Methodological Guide and the systematic review structure will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

The Effect of Non-pooled Multidonor Faecal Microbiota Transplantation for Inducing Clinical Remission in Patients with Chronic Pouchitis: Results from a Multicentre, Randomised, Double-blinded, Placebo-controlled Trial [MicroPouch]

BACKGROUND AND AIMS

To investigate if treatment with non-pooled, multidonor faecal microbiota transplantation [FMT] for 4 weeks was superior to placebo to induce clinical remission in patients with chronic pouchitis.

METHODS

The study was a randomised, double-blinded, placebo-controlled study with a 4-week intervention period and 12-month follow-up. Eligible patients with chronic pouchitis were recruited from five Danish hospitals. Participants were randomised to non-pooled, multidonor FMT derived from four faecal donors, or placebo. Treatment was delivered daily by enema for 2 weeks, followed by every second day for 2 weeks. Disease severity was accessed at inclusion and 30-day follow-up, using the Pouchitis Disease Activity Index [PDAI]; PDAI <7 was considered equivalent to clinical remission. Faecal samples from participants and donors were analysed by shotgun metagenomic sequencing.

RESULTS

Inclusion was stopped after inclusion of 30 participants who were randomised 1:1 for treatment with FMT or placebo. There was no difference in participants achieving clinical remission between the two groups at 30-day follow-up, relative risk 1.0 (95% CI [0.55; 1.81]). Treatment with FMT resulted in a clinically relevant increase in adverse events compared with placebo, incidence rate ratio 1.67 (95% CI [1.10; 2.52]); no serious adverse events within either group. Faecal microbiota transplantation statistically significantly increased the similarity of participant faecal microbiome to the faecal donor microbiome at 30-day follow-up [p = 0.01], which was not seen after placebo.

CONCLUSIONS

Non-pooled, multidonor FMT was comparable to placebo in inducing clinical remission in patients with chronic pouchitis, but showed a clinically relevant increase in adverse events compared with placebo. ClincialTrials.gov number, NCT04100291.

Perioperative Enhanced Recovery Concepts Significantly Improve Postoperative Outcome in Patients with Crohn`s Disease

BACKGROUND AND AIMS

Despite recent advancements in medical and surgical techniques in patients suffering from Crohn`s disease [CD], postoperative morbidity remains relevant due to a long-standing, non-curable disease burden. As demonstrated for oncological patients, perioperative enhanced recovery concepts provide great potential to improve postoperative outcome. However, robust evidence about the effect of perioperative enhanced recovery concepts in the specific cohort of CD patients is lacking.

METHODS

In a prospective, single-centre study, all patients receiving ileocaecal resection due to CD between 2020 and 2023 were included. A specific, perioperative, enhanced recovery concept [ERC] was implemented and patients were divided into two groups [before and after implementation]. The primary outcome focused on postoperative complications as measured by the Comprehensive Complication Index [CCI], secondary endpoints were severe complications, length of hospital stay, and rates of re-admission.

RESULTS

Of 83 patients analysed, 33 patients participated in the enhanced recovery programme [post-ERC]. Whereas patient characteristics were comparable between both groups, ERC resulted in significantly decreased rates of overall and severe postoperative complications [CCI: 21.4 versus 8.4, p = 0.0036; Clavien Dindo > 2: 38% versus 3.1%, p = 0.0002]. Additionally, post-ERC-patients were ready earlier for discharge [5 days versus 6.5 days, p = 0.001] and rates of re-admission were significantly lower [3.1% versus 20%, p = 0.03]. In a multivariate analysis, the recovery concept was identified as independent factor to reduce severe postoperative complications [p = 0.019].

CONCLUSION

A specific, perioperative, enhanced recovery concept significantly improves the postoperative outcome of patients suffering from Crohn`s disease.

Clinical practices in the management and follow-up of obstetric anal sphincter injuries: a comprehensive review

OBJECTIVES

To review and compare existing guidelines on the intrapartum management and postpartum follow-up of obstetric anal sphincter injuries (OASIS) METHODS: We conducted a systematic review of clinical guidelines related to OASIS management, focusing on intrapartum care and postpartum follow-up. Searches were performed in July 2024 across multiple databases, including PubMed, Embase, and the Cochrane Library. Guidelines published after 2010 in English were included.

RESULTS

Nine national guidelines were included. There was a consensus on OASIS classification and immediate management, particularly regarding suture techniques, materials, and the necessity of adequate analgesia. However, notable variations were identified in the timing of repair, specialist involvement, use of prophylactic antibiotics, and post-operative care protocols. Postpartum follow-up practices also varied, especially regarding the role of physiotherapy and the timing of specialist consultations, reflecting inconsistencies in long-term care recommendations.

CONCLUSION

Significant variability existed in the guidelines for the management and follow-up of OASIS, particularly in postpartum care. This study underscored the need for standardized, evidence-based guidelines to ensure consistent and optimal care for women affected by OASIS.

Recovery of gastrointestinal functional after surgery for abdominal tumors: A narrative review

Postoperative gastrointestinal dysfunction, including temporary nonmechanical suppression of gastrointestinal motility (known as postoperative ileus), occurs in about 10% surgeries of abdominal tumors. Since these complications can prolong hospitalization and affect eating, it is important to understand their risk factors and identify effective interventions to manage or prevent them. The present review comprehensively examined the relevant literature to describe risk factors for postoperative ileus and effective interventions. Risk factors include old age, open surgery, difficulty of surgery, surgery lasting longer than 3 hours, preoperative bowel treatment, infection, and blood transfusion. Factors that protect against postoperative ileus include early enteral nutrition, minimally invasive surgery, and multimodal pain treatment. Interventions that can shorten or prevent such ileus include minimally invasive surgery, early enteral nutrition as well as use of chewing gum, laxatives, and alvimopan. Most of these interventions have been integrated into current guidelines for enhanced recovery of gastrointestinal function after surgery. Future high-quality research is needed in order to clarify our understanding of efficacy and safety.

Haemorrhoid artery ligation - recto anal repair (HAL-RAR) blind versus Doppler: a systematic review and meta-analysis

BACKGROUND

Haemorrhoids remain a highly prevalent condition in Australia, affecting 39% of the adult Australian population. While haemorrhoidectomy remains the gold standard in the management of haemorrhoids, newer techniques such as haemorrhoid artery ligation-recto anal repair (HAL-RAR) are emerging as promising management modalities. We compare the efficacy of non-Doppler guided (non-DG) HAL-RAR versus Doppler-guided (DG) HAL-RAR in the management of haemorrhoids.

METHODS

This study was registered with PROSPERO (CRD42022353806) and adhered to PRISMA 2020 guidelines. We conducted a systematic review using Medline, Embase and Cochrane database for comparative studies between Doppler-guided HAL-RAR and non-Doppler-guided HAL-RAR in accordance with the PRISMA 2020 statement for reporting systematic reviews.

RESULTS

Five studies were included in our systematic review and meta-analysis. There was no clinically significant difference in operative times (SMD 0.46, 9% CI -3.16 0 4.08, P = 0.804) or post-operative bleeding (P = 0.142) between the two groups. DG HAL-RAR patients were more likely to have post-operative urinary retention (P < 0.001). Non-DG patients were less likely to experience recurrence (OR 5.12, P < 0.001).

CONCLUSION

Our review of non-DG HAL-RAR compared to DG HAL-RAR reflects the non-inferiority of the non-DG HALRAR procedure. We hope that these results would provide a guide to clinicians performing HAL-RAR, and would provide some cost savings for institutions who are unable to procure the necessary equipment for DG HAL-RAR.

Surgical and non-surgical risk factors affecting the insufficiency of ileocolic anastomosis after first-time surgery in Crohn's disease patients

BACKGROUND

Crohn's disease (CD) often necessitates surgical intervention, particularly when it manifests in the terminal ileum and ileocecal valve. Despite undergoing radical surgery, a subset of patients experiences recurrent inflammation at the anastomotic site, necessitating further medical attention.

AIM

To investigate the risk factors associated with anastomotic insufficiency following ileocecal resection in CD patients.

METHODS

This study enrolled 77 patients who underwent open ileocolic resection with primary stapled anastomosis. Patients were stratified into two groups: Group I comprised individuals without anastomotic insufficiency, while Group II included patients exhibiting advanced anastomotic destruction observed endoscopically or those requiring additional surgery during the follow-up period. Surgical and non-surgical factors potentially influencing anastomotic failure were evaluated in both cohorts.

RESULTS

Anastomotic insufficiency was detected in 12 patients (15.6%), with a mean time interval of 30 months between the initial surgery and recurrence. The predominant reasons for re-intervention included stenosis and excessive perianastomotic lesions. Factors associated with a heightened risk of anastomotic failure encompassed prolonged postoperative obstruction, anastomotic bleeding, and clinically confirmed micro-leakage. Additionally, patients in Group II exhibited preoperative malnutrition and early recurrence of symptoms related to CD.

CONCLUSION

Successful surgical outcomes hinge on the attainment of a fully functional anastomosis, optimal metabolic status, and clinical remission of the underlying disease. Vigilant endoscopic surveillance following primary resection facilitates the timely identification of anastomotic failure, thereby enabling noninvasive interventions.

Impact of robotic surgery on postoperative gastrointestinal dysfunction following minimally invasive colorectal surgery: incidence, risk factors, and short-term outcomes

AIM

Postoperative gastrointestinal dysfunction (POGD) is a common complication following colorectal surgery. This study aimed to investigate the incidence and risk factors of POGD after minimally invasive surgery and to assess the relationship between robotic surgery, POGD, and their outcomes.

METHOD

Patients who had undergone minimally invasive colorectal surgery at our institution between July 2018 and November 2023 were retrospectively enrolled. POGD was diagnosed based on the presence of two or more intestinal symptoms within 72 h or more after surgery. Risk factors were identified through regression analyses, and the impact of POGD on outcomes was assessed using linear regression.The association between those factors was assessed using subgroup analysis and hierarchical regression.

RESULTS

A total of 226 patients were included in the analysis, including 33 with POGD. POGD occurred in 14.6% of patients, with a lower incidence in robotic surgery (7.3%) than in laparoscopic surgery (19.8%). Multivariate analysis indicated that robotic surgery had a protective effect, while blood loss exceeding 50 ml was an independent risk factor for POGD. POGD was also correlated with longer length of stays and higher costs. The association between POGD, length of stay, and cost varied depending on the surgical platform. Robotic surgery exacerbated the effect of POGD on short-term outcomes, which aligned with the observed significant interaction effect.

CONCLUSION

POGD remains a prevalent postoperative disease. Preventive strategies, including meticulous hemostasis techniques and robotic surgery, should be prioritized by healthcare professionals to reduce POGD risk, improve short-term outcomes, and preserve healthcare resources.

Diverticulitis Management in Complex Medical Contexts

Diverticulitis is a prevalent medical issue, particularly among elderly individuals in the Western world. Management is nuanced and is influenced by both disease presentation and patient factors, especially those that affect risk of septic and surgical complications. This paper reviews existing literature to explore the incidence, presentation, and management of diverticulitis in complex medical contexts—immunocompromised populations, specifically highlighting those undergoing chemotherapy, HIV/AIDS patients, transplant recipients, and individuals with autoimmune and connective tissue diseases. Not surprisingly, management of diverticulitis in these complex patient populations is associated with increased morbidity. However, even taking into consideration the risk of septic and surgical complications, more recent data and treatment recommendations suggest that both nonoperative and operative management strategies may be appropriate based on individual patient presentations, mirroring the treatment paradigm of immunocompetent patients. In addition, in discussing operative management of complex medical patients, immunosuppression alone should not be considered a contraindication to primary anastomosis. Overall, there are limited existing data on diverticulitis in immunocompromised populations and, especially, patients with autoimmune and connective tissue disorders. Further research is warranted to better understand the impact of these chronic diseases on diverticulitis severity and to best inform evidence-based practices in this complex clinical scenario.

Global Outcomes Benchmarks in Laparoscopic Liver Surgery for Segments 7 and 8: International Multicenter Analysis

BACKGROUND

In recent years, there has been growing interest in laparoscopic liver resection (LLR) and the audit of the results of surgical procedures. The aim of this study was to define reference values for LLR in segments 7 and 8.

STUDY DESIGN

Data on LLR in segments 7 and 8 between January 2000 and December 2020 were collected from 19 expert centers. Reference cases were defined as no previous hepatectomy, American Society of Anesthesiologists score less than 3, BMI less than 35 kg/m 2 , no chronic kidney disease, no cirrhosis and portal hypertension, no COPD (forced expiratory volume 1 <80%), and no cardiac disease. Reference values were obtained from the 75th percentile of the medians of all reference centers.

RESULTS

Of 585 patients, 461 (78.8%) met the reference criteria. The overall complication rate was 27.5% (6% were Clavien-Dindo 3a or more) with a mean Comprehensive Complication Index of 7.5 ± 16.5. At 90-day follow-up, the reference values for overall complication were 31%, Clavien-Dindo 3a or more was 7.4%, conversion was 4.4%, hospital stay was less than 6 days, and readmission rate was <8.33%. Patients from Eastern centers categorized as low risk had a lower rate of overall complication (20.9% vs 31.2%, p = 0.01) with similar Clavien-Dindo 3a or more (5.5% and 4.8%, p = 0.83) compared with patients from Western centers, respectively.

CONCLUSIONS

This study shows the need to establish standards for the postoperative outcomes in LLR based on the complexity of the resection and the location of the lesions.

Bullying within specialist medical training in Australia: Analysis of the medical training survey, 2020-2023

OBJECTIVE

Bullying is common in medical specialist training in Australia. To understand bullying rates across medical specialist training programs, we analyse the recent Medical Training Survey, administered by the Medical Board of Australia to all registered medical practitioners.

METHODS

Medical Training Survey data were extracted and averaged from 2020 to 2023.

RESULTS

Many speciality trainees reported personally experiencing or witnessing bullying. This was lowest in general practice (13% personally experienced and 15% witnessed) and highest in obstetrics and gynaecology (27% and 41%). The highest rate of bullying by supervisors was in surgery: 60% of surgical trainees stated that when they were bullied it was by their supervisor. Within psychiatry, 22% of trainees had personally experienced bullying and 32% of trainees had witnessed bullying. When they were bullied, the perpetrator was less commonly a supervisor (40%). In all specialities, there was a very low percentage of bullying which was reported, and was identified as having a satisfactory outcome: the most satisfactory outcomes (13%) were in general practice.

CONCLUSION

Current rates of bullying for medical specialist trainees, the reluctance to report, as well as the lack of satisfactory outcomes, is of grave concern for Australian healthcare. This requires urgent attention at a systems level.

Quality of life and symptom burden after rectal cancer surgery: a randomised controlled trial comparing patient-led versus standard follow-up

PURPOSE

After curatively intended rectal cancer (RC) surgery, new follow-up strategies are warranted, seeking more individualised care and targeting health-related quality of life (HRQoL) and functional outcomes. The FURCA trial aimed to investigate the effect of patient-led follow-up on HRQoL and symptom burden 3 years after surgery.

METHODS

RC patients from four Danish centres were randomised 1:1 to intervention (patient-led follow-up with patient education and self-referral to a specialist nurse) or control (standard follow-up with five routine doctor visits). Patients in both groups had a computed tomography (CT) at 1 and 3 years. The primary outcome (HRQoL) was assessed by the Functional Assessment of Cancer Therapy - colorectal (FACT-C) score (Ward et al. in Qual Life Res. 8(3):181-95, 18). Secondary outcomes were functional measures, patient involvement and satisfaction and cancer recurrence at 3 years.

RESULTS

From Feb 2016 to Aug 2018, 336 patients were included of whom 248 completed 3 years of follow-up. Between-group differences were found neither for the primary endpoint, nor for functional outcomes. The recurrence rate did not differ between the groups. Patient involvement and satisfaction were higher in the intervention group with statistical significance in almost half of the items.

CONCLUSIONS

We found no effect on HRQoL and symptom burden from patient-led follow-up, although it may improve patient-perceived involvement and satisfaction.

IMPLICATIONS FOR CANCER SURVIVORS

The findings in this study suggest that patient-led follow-up is a more tailored approach to meet cancer survivors' needs and might improve their ability to cope with survivorship.

CLINICALTRIALS

GOV IDENTIFIER

R97-A6511-14-S23.

Benchmarking in pancreatic surgery: a systematic review of metric development and validation

Benchmarking in healthcare, particularly in the context of complex surgical procedures like pancreatic surgery, plays a pivotal role in comparing and evaluating the quality of care provided to patients. There is a growing body of evidence validating existent metrics and introducing new ones in the pursuit of safety and excellence in pancreatic surgery. A systematic review adhering to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted on metric development and validation across multiple databases, including PUBMED Medline, Scopus, and Web of Science, until February 2024. The extracted data were categorized into three domains according to the Donabedian model: structure, process, and outcomes. Thirty-four studies were deemed eligible for inclusion in this review. Among these articles, 20 contributed to metric development, while 14 studies validated them. A total of 234 metrics were identified across the 34 studies, of which 185 were included in the analysis. Thirty-three of these metrics were relative to structure, 79 to processes, and 73 to outcomes. The distribution of metric domains across the included studies revealed that structure, process, and outcome domains were reported in 12, 26, and 26 studies, respectively. In conclusion, this systematic review underscores the heterogeneity in metric development methodologies and the varying degrees of consensus among different quality indicators, despite the growing interest in benchmarking in pancreatic surgery. This review aims to inform future research efforts and contribute to the ongoing pursuit of excellence in pancreatic surgical care.

Current insights on social media as a tool for the dissemination of research and education in surgery: a narrative review

The purpose of our narrative review is to summarize the utilization of social media (SoMe) platforms for research communication within the field of surgery. We searched the PubMed database for articles in the last decade that discuss the utilization of SoMe in surgery and then categorized the diverse purposes of SoMe. SoMe proved to be a powerful tool for disseminating articles. Employing strategic methods like visual abstracts enhances article citation rates, the impact factor, h-index, and Altmetric score (an emerging alternative metric that comprehensively and instantly quantifies the social impact of scientific papers). SoMe also proved valuable for surgical education, with online videos shared widely for surgical training. However, it is essential to acknowledge the associated risk of inconsistency in quality. Moreover, SoMe facilitates discussion on specific topics through hashtags or closed groups and is instrumental in recruiting surgeons, with over half of general surgery residency programs in the US efficiently leveraging these platforms to attract the attention of potential candidates. Thus, there is a wealth of evidence supporting the effective use of SoMe for surgeons. In the contemporary era where SoMe is widely utilized, surgeons should be well-versed in this evidence.

Two-stage cytoreductive surgery for 'extensive' pseudomyxoma peritonei: A legitimate alternative or salvage strategy?

BACKGROUND AND AIM

Two-stage cytoreductive surgery (CRS) has been proposed as an alternative to one-stage surgery in patients who have 'extensive' pseudomyxoma peritonei (PMP) and/or are unfit for very extensive surgery, to reduce morbidity. We review current evidence on two-stage CRS focusing on patient selection, interval between procedures, extent of surgery, use of HIPEC, perioperative and oncological outcomes.

METHODS

This is a narrative review. A literature search on PubMed and Embase was performed using keywords- 'Two-stage cytoreductive surgery', 'pseudomyxoma peritonei', 'high-volume PMP', 'huge PMP', 'cytoreductive surgery', 'HIPEC', 'staged surgery' and 'extensive pseudomyxoma peritonei'.

RESULTS

Five studies reported outcomes in a total of 114 patients. The indications for two-stage CRS were: in two studies, patients undergoing an incomplete cytoreduction due to undue surgical risk were reevaluated for a second surgery during routine surveillance; severe comorbidities in one; extensive disease with PCI>28 in another and in one, only HIPEC was performed as a second procedure due to intraoperative hemodynamic instability (the two-stage procedure was performed in interest of patient's safety). Major morbidity ranged from 0 to 37.5 % (first-stage) and 25%-38.9 % (second-stage). Short term follow-up demonstrated equivalent short-term oncological outcomes compared to historical data. Long term follow-up and quality-of-life data were not available.

CONCLUSIONS

The published studies showed different interpretations and applications of the two-stage CRS concept. The reported morbidity was similar to that after single-stage CRS for extensive PMP. Though short-term survival outcomes are acceptable, long-term follow-up is needed. Planned two-stage CRS should currently be reserved for highly selected clinical situations.

Simple pelvimetry predicts the pelvic manipulation time in robot-assisted low and ultra-low anterior resection for rectal cancer

PURPOSE

This study explored the difficulty factors in robot-assisted low and ultra-low anterior resection, focusing on simple measurements of the pelvic anatomy.

METHODS

This was a retrospective analysis of the clinical data of 61 patients who underwent robot-assisted low and ultra-low anterior resection for rectal cancer between October 2018 and April 2023. The relationship between the operative time in the pelvic phase and clinicopathological data, especially pelvic anatomical parameters measured on X-ray and computed tomography (CT), was evaluated. The operative time in the pelvic phase was defined as the time between mobilization from the sacral promontory and rectal resection.

RESULTS

Robot-assisted low and ultra-low anterior resections were performed in 32 and 29 patients, respectively. The median operative time in the pelvic phase was 126 (range, 31-332) min. A multiple linear regression analysis showed that a short distance from the anal verge to the lower edge of the cancer, a narrow area comprising the iliopectineal line, short anteroposterior and transverse pelvic diameters, and a small angle of the pelvic mesorectum were associated with a prolonged operative time in the pelvic phase.

CONCLUSION

Simple pelvic anatomical measurements using abdominal radiography and CT may predict the pelvic manipulation time in robot-assisted surgery for rectal cancer.

Systemic sclerosis and anorectal dysfunction: The Leeds experience

Systemic sclerosis is an autoimmune disorder which frequently affects the gastrointestinal tract. Anorectal dysfunction is common in systemic sclerosis and is manifested mainly by atrophy of internal anal sphincter. Faecal incontinence is the result of internal anal sphincter atrophy secondary to systemic sclerosis. In this study, we aimed to assess the internal anal sphincter in 17 patients with faecal incontinence and systemic sclerosis using anorectal manometry and endoanal ultrasound and compare them with an age and gender-matched control group without systemic sclerosis. Most patients have limited cutaneous systemic sclerosis. Majority of the patients with systemic sclerosis and faecal incontinence presented with symptoms of faecal leakage and urgency. Systemic sclerosis patients had low basal sphincter pressures. The mean thickness of internal anal sphincter in systemic sclerosis group was significantly lower than the control group (p < 0.001). Rectal sensation is preserved in systemic sclerosis. There was no difference in the mean thickness of the external anal sphincter between the two groups. To conclude internal anal sphincter is atrophic in systemic sclerosis resulting in decreased resting sphincter pressures and passive faecal leakage. Further investigations and studies are needed to determine the natural course of faecal incontinence in systemic sclerosis, associated risk factors and efficacy of therapeutic interventions.

Surgeons with disabilities, they do exist

INTRODUCTION

Doctors with disability are likely to face major life crises, challenges and distressing emotions from unforeseen circumstances that threaten their physical well-being. We aimed to identify the existence of work-related pain and discomfort that may cause surgeon's disability. Surgeons who were struck with unpredictable disasters leading to disabilities were also reviewed.

METHODS

We conducted a 10-year literature review. In addition, citations about surgeons' physical disabilities were complemented with commentaries about disabled surgeons from gray literature. The quantitative citations were quality assessed by MERSQI scores and evidence graded according to GRADE. For the qualitative study part, the severely traumatized surgeons were analysed by means of Cullberg's crisis phases (CCP) and analysed from Tedeschi and Calhoun's post-traumatic growth perspective (PTG).

RESULTS

Altogether 3593 citations from PubMed were studied, and 10 citations met inclusion criteria with a total of 11591 participants. We included 6 surgeons subjected to highly traumatic events complicating their medical career. Our quantitative citations' mean MERSQI score was 11.73 (SD .79) and the citations' evidence value completed grade II (moderate quality: 11.26 to 12.00 scores). Work-related musculoskeletal pain and occupational injuries may lead to physical disabilities. The accidentally traumatized surgeons fought through the four CCP phases and reached successfully the PTG stage.

CONCLUSIONS

The surgical workforce is at high risk of work-related musculoskeletal morbidity which can progress to chronic pain and disruption of surgeon's career. Surgeons with disabilities faced serious barriers in their career. Institutions and healthcare systems must urgently develop support strategies for surgeons with disabilities.

Global treatment of haemorrhoids-A worldwide snapshot audit conducted by the International Society of University Colon and Rectal Surgeons

AIM

There is no universally accepted treatment consensus for haemorrhoids, and thus, management has been individualized all over the world. This study was conducted to assess a global view of how surgeons manage haemorrhoids.

METHODS

The research panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) developed a voluntary, anonymous questionnaire evaluating surgeons' experience, volume and treatment approaches to haemorrhoids. The 44 multiple-choice questionnaire was available for one month via the ISUCRS email database and the social media platforms Viber and WhatsApp.

RESULTS

The survey was completed by 1005 surgeons from 103 countries; 931 (92.6%) were in active practice, 819 (81.5%) were between 30 and 60 years of age, and 822 (81.8%) were male. Detailed patient history (92.9%), perineal inspection (91.2%), and digital rectal examination (91.1%) were the most common assessment methods. For internal haemorrhoids, 924 (91.9%) of participants graded them I-IV, with the degree of haemorrhoids being the most important factor considered to determine the treatment approach (76.3%). The most common nonprocedural/conservative treatment consisted of increased daily fibre intake (86.9%), increased water intake (82.7%), and normalization of bowel habits/toilet training (74.4%). Conservative treatment was the first-line treatment for symptomatic first (92.5%), second (72.4%) and third (47.3%) degree haemorrhoids; however, surgery was the first-line treatment for symptomatic fourth degree haemorrhoids (77.6%). Rubber band ligation was the second-line treatment in first (50.7%) and second (47.2%) degree haemorrhoids, whereas surgery was the second-line treatment in third (82.9%) and fourth (16.7%) degree symptomatic haemorrhoids. Rubber band ligation was performed in the office by 645(64.2%) of the participants. The most common surgical procedure performed for haemorrhoids was an excisional haemorrhoidectomy for both internal (87.1%) and external (89.7%) haemorrhoids - with 716 (71.2%) of participants removing 1, 2 or 3 sectors as necessary.

CONCLUSION

Although there is no global haemorrhoidal treatment consensus, there are many practice similarities among the different cultures, resources, volume and experience of surgeons around the world. With additional studies, a consensus statement could potentially be developed.

Effect and impression of structured feedback in formative assessment of medical undergraduates of Eastern India

Feedback, the integral component of formative assessment, should be timely, specific, and methodical. Feedback is a stop-gap that helps the learner to assess their performance and reinforce their desire to learn. This study was conducted to explore the effectiveness of feedback in improving the performance of medical undergraduates in formative assessment and assessment of perceptions of students about feedback. This comparative interventional study was conducted to monitor the improvement in formative assessment scores after the structured feedback. Medical undergraduates of phase1 (Bachelor of Medicine and Bachelor of Surgery (MBBS) Batch 2022-2023) of Bankura Sammilani Medical College and Hospital were included as the study participants. The proportion of students having scores <50% and >50% between the two formative assessments were compared using the Chi-square test. A questionnaire in the Likert scale was devised to assess the perception of students regarding quality of feedback and analyzed by Tastle and Wierman formula. The number of students scoring > 50% as well as their mean formative assessment scores increased significantly after feedback (P = 0.0009). The majority of the students proclaimed that feedback was non-judgmental and motivated for the study. Feedback motivated students to assess their deficits and encouraged the desire to study to overcome the lacunae. The majority of the students (65.9%) strongly voiced that the feedback was effective, valuable, and non-judgmental.

Global research trends in postoperative ileus from 2011 to 2023: A scientometric study

BACKGROUND

Postoperative ileus (POI) is a common complication after abdominal surgery with high morbidity, which hinders patient recovery, prolongs hospitalization, and increases healthcare costs. Therefore, POI has become a global public health challenge. POI triggering is multifactorial. Autonomic and hormonal mechanisms are generally involved in POI pathogenesis. Recent studies have shown that beta adrenergic signaling of enteric glia is a POI trigger. Currently, the status quo, trends, and frontiers of global research on POI remain unclear.

AIM

To explore the current status, trends, and frontiers of POI research from 2011 to the present based on bibliometric analysis.

METHODS

Publications published on POI research from 2011 to 2023 were retrieved on June 1, 2023, from the Web of Science Core Collection. CiteSpace 6.2.R2 and VOSviewer were used to conduct bibliometric visualization.

RESULTS

In total, 778 POI records published from 2011 to 2023 were retrieved. Over the past few decades, the annual cumulative number of related articles has linearly increased, with China and the United States of America contributing prominently. All publications were from 59 countries and territories. China and the University of Bonn were the top contributing country and institution, respectively. Neurogastroenterology & Motility was the most prolific journal. The Journal of Gastrointestinal Surgery had the highest number of citations. Wehner Sven was the most productive author. Burst keywords (e.g., colon, prolonged ileus, acupuncture, paralytic ileus, pathophysiology, rectal cancer, gastrointestinal function, risk) and a series of reference citation bursts provided evidence for the research frontiers in recent years.

CONCLUSION

This study demonstrates trends in the published literature on POI and provides new insights for researchers. It emphasizes the importance of multidisciplinary cooperation in the development of this field.

Development and validation of an MRI and clinicopathological factors prediction model for low anterior resection syndrome in anterior resection of middle and low rectal cancer

OBJECTIVE

To validate the predictive power of newly developed magnetic resonance (MR) morphological and clinicopathological risk models in predicting low anterior resection syndrome (LARS) 6 months after anterior resection of middle and low rectal cancer (MLRC).

METHODS

From May 2018 to January 2021, 236 patients with MLRC admitted to two hospitals (internal and external validation) were included. MR images, clinicopathological data, and LARS scores (LARSS) were collected. Tumor morphology data included longitudinal involvement length, maximum tumor diameter, proportion of tumor to circumference of the intestinal wall, tumor mesorectal infiltration depth, circumferential margin status, and distance between the tumor and anal margins. Pelvic measurements included anorectal angle, mesenterial volume (MRV), and pelvic volume. Univariate and multivariate logistic regression was used to obtain independent risk factors of LARS after anterior resection Then, the prediction model was constructed, expressed as a nomogram, and its internal and external validity was assessed using receiver operating characteristic curves.

RESULTS

The uni- and multivariate analysis revealed distance between the tumor and anal margins, MRV, pelvic volume, and body weight as significant independent risk factors for predicting LARS. From the nomogram, the area under the curve (AUC), sensitivity, and specificity were 0.835, 75.0 %, and 80.4 %, respectively. The AUC, sensitivity, and specificity in the external validation group were 0.874, 83.3 %, and 91.7 %, respectively.

CONCLUSION

This study shows that MR imaging and clinicopathology presented by a nomogram can strongly predict LARSS, which can then individually predict LARS 6 months after anterior resection in patients with MLRC and facilitate clinical decision-making.

CLINICAL RELEVANCE STATEMENT

We believe that our study makes a significant contribution to the literature. This method of predicting postoperative anorectal function by preoperative measurement of MRV provides a new tool for clinicians to study LARS.

Striving Through Adversities of Professional Life to Provide Better Care: A Content Analysis of News Articles and Online Blogs on Deteriorating Mental Health of Medicos

Background

One of the noblest professions is medicine, which comprises ancillary services, medical students, and other paramedics. The challenges faced by the medical fraternity are infinite and uncertain.

Aim

This study aims to thoroughly understand the professional challenges faced by medical professionals that can lead to mental health issues.

Methods

A content analysis of 64 news articles and online blogs was done. The articles and blogs that addressed mental health issues among medical professionals were shortlisted. The data retrieved was accessed digitally between 2016 and 2024. Frequency analysis was done using QDA Miner Lite (free version).

Results

The findings were summarized into six themes and 17 sub-themes, showing a high frequency of rising mental health issues among medicos, lack of organizational support, poor work-life balance, violence, and sacrificed health, with other less frequent codes like toxic seniority, hostile work culture, negative consequences of reporting mental health problems and hiding vulnerability to protect self-efficacy.

Conclusion

The data retrieved from various news articles and blogs presents the personal experiences and real-life struggles of medical professionals. The outcome of this study is to understand the key issues affecting medicos at personal, professional, social, emotional, and spiritual levels.

Alvimopan for postoperative ileus following abdominal surgery: a systematic review

BACKGROUND

Postoperative ileus (POI) is a common complication following abdominal surgery, often leading to extended hospital stays and a higher risk of post-operative complications, leading to poorer patient outcomes. Alvimopan, a peripherally acting µ-opioid receptor antagonist, has been shown to aid in the recovery of normal bowel function after surgery. While its benefits are well-established in open abdominal surgeries, its efficacy in laparoscopic procedures had not been conclusively determined. However, recent clinical trials involving laparoscopic surgeries have since been conducted. This review aims to reassess the efficacy of Alvimopan by incorporating findings from these new studies, potentially providing further insight into its clinical benefits.

METHODS

A comprehensive search of PubMed, Google Scholar, EMBASE, and the Cochrane Library was conducted. Studies were included based on the PICO framework, focusing on Alvimopan's impact on postoperative gastrointestinal recovery. Primary outcomes were time to gastrointestinal function recovery (GI-3) and hospital stay duration.

RESULTS

Ten studies met the inclusion criteria, with seven focusing on the use of Alvimopan in open abdominal surgeries and three in laparoscopic procedures. Collectively, these studies involved 18,822 patients undergoing various types of abdominal Administration of Alvimopan 6 mg accelerated gastrointestinal function recovery by an average of 14 h (Hazard ratio: 1.62, p = 0.002) and reduced hospital stays by 5.2 h (Hazard ratio: 1.52, p = 0.04) compared to placebo. Similarly, Alvimopan 12 mg reduced GI-3 recovery time by 13.5 h (Hazard ratio: 1.58, p = 0.02) and hospital stay duration by 6.2 h (Hazard ratio: 1.46, p = 0.018).

CONCLUSION

Alvimopan shows promise in reducing POI and hospital stay durations following abdominal surgeries. The incorporation of the recent studies in laparoscopic abdominal procedures further supports these findings. Integrating Alvimopan into perioperative care protocols may enhance patient outcomes and help lower healthcare costs.

Advantages of robotic surgery for rectal cancer compared to laparoscopic surgery: pelvic anatomy and its impact on urinary dysfunction

The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD.

Nursing care services to address unmet supportive care needs among cancer survivors: a systematic review

BACKGROUND

The increasing population of cancer survivors poses a significant challenge for healthcare systems globally, necessitating comprehensive post-treatment care to address diverse physical, psychological, and social needs.

OBJECTIVE

This systematic review aims to synthesize and critically evaluate the current evidence concerning the unmet needs for nursing services among cancer survivors, spanning various dimensions of survivorship care.

METHODS

A systematic search was conducted across major databases, including PubMed, CINAHL, and PsycINFO, to identify relevant studies investigating the unmet needs and health-related quality-of-life (HRQOL) of nursing services led by nurses among cancer survivors. The final search update was conducted in June 2024. Unmet needs dimensions were categorized by the biopsychosocial-spiritual framework.

RESULTS

Of the 9503 records searched, 18 studies were included. This review revealed mixed findings in the domains of unmet needs and interventions aimed at addressing them. While nurse-led interventions showed promise in addressing physical and daily living needs, outcomes related to psychological and emotional needs varied across studies. Additionally, nurse-led interventions were effective in addressing patient-clinician communication and health system/information needs, although statistical significance was not consistently observed. HRQOL assessments using general and cancer-specific measures yielded mixed findings.

CONCLUSIONS

Despite limitations of the risk of bias of included studies and weak study designs for evaluating nurse-led intervention effects for cancer survivors, the findings highlight the potential of nursing practice to significantly contribute to improving unmet needs of physical, psychological, and social perspectives and ultimately improving their HRQOL. However, the impact on the spiritual needs of nursing care services is limited by the low number of studies.

IMPLICATIONS FOR CANCER SURVIVORS

By providing comprehensive support and management, nursing practice can enhance post-treatment outcomes and HRQOL for cancer survivors, contributing to more patient-centered and effective care delivery. More rigorous research considering a biopsychosocial-spiritual perspective to help cancer survivors improve HRQOL is needed.

Public Knowledge and Awareness About Hemorrhoids and the Reasons for Late Presentation to Local Doctors in Makkah Region, Saudi Arabia: A Cross-Sectional Exploratory Study

Background Hemorrhoids, also known as piles, manifest as anal lumps with or without bleeding. This study aims to explore and assess the public knowledge and awareness about hemorrhoids and the factors leading to late presentation to local doctors in the Makkah region of Saudi Arabia. Methodology A questionnaire-based, cross-sectional study was conducted targeting the Saudi population aged 18 years and more living in the Makkah region. The study was conducted from May 1 to May 29, 2023. Data collection was done using electronic Google Forms for data collection. The questionnaire was divided into three main sections covering demographics, knowledge items, and personal and family history of hemorrhoids. Results A total of 495 participants completed the study questionnaire. Participants' ages ranged from 18 to 65 years with a mean age of 25.1 ± 13.7 years old. Overall, 414 (83.6%) were males. Only 106 (21.4%) had an overall good knowledge level. The majority of the participants (78.6%, 389) had poor knowledge. Pain (78% of the participants) was the most common reason for seeking medical advice, followed by feeling uncomfortable (43.3%), and the presence of blood or blood spots in the stool (41.1%). Among others who never sought medical advice, the most reported reason was being embarrassed (66.7%). Conclusions This study revealed that the prevalence of early seeking medical advice was low as many did not because of stigma. The main reasons for seeking medical care were disease-related symptoms, and embarrassment was the main reported barrier.

Double-row staple technology versus triple-row staple technology for colorectal surgery: A systematic review and meta-analysis

BACKGROUND

Some observational data have suggested that anastomotic leak may be reduced with triple-row staple technology compared to double-row staple technology. We aimed to investigate this further by performing a systematic review comparing double- and triple-row staple technology for colorectal anastomoses.

METHODS

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to November 2023. Articles were eligible for inclusion if they were comparing double-row staple and triple-row staple technology for left-sided colo-colic, colorectal, or coloanal anastomosis. The main outcomes included anastomotic leak, anastomotic hemorrhage, 30-day mortality, and reoperation. Meta-analyses with inverse variance random effects were performed. Certainty of evidence was assessed with Grading of Recommendations, Assessment, Development, and Evaluations.

RESULTS

After reviewing 340 relevant citations, 6 retrospective cohort studies met inclusion. Overall, 19,372 patients (mean age: 60.2 years, 52.7% female sex) had anastomoses with double-row staple technology, and 2,298 patients (mean age: 61.3 years, 50.3% female sex) with triple-row staple technology. Most operations were anterior resections (double-row: 55.3%; triple-row: 43.6%). Across all included studies, the risk of anastomotic leak was reduced with triple-row staple technology (6.3% vs 7.5%, risk ratio 0.54, 95% confidence interval 0.31-0.94, P = .03, I2=75%). There were no significant differences in anastomotic hemorrhage (risk ratio 0.47, 95% confidence interval 0.15-1.49, P = .20, I2 = 57%), 30-day mortality (risk ratio 0.66, 95% confidence interval 0.17-2.55, P = .55, I2 = 0%), or reoperation (risk ratio 1.05, 95% confidence interval 0.42-2.64, P = .91, I2 = 56%).

CONCLUSION

Triple-row staple technology may reduce the risk of anastomotic leak in left-sided colorectal anastomoses.

Is Hyperthermic Intraperitoneal Chemotherapy Appropriate for Colon Cancer?

Colorectal cancer (CRC) with peritoneal metastases is a complex disease and its management presents significant clinical challenges. In well-selected patients at experienced centers, CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed with acceptable morbidity and is associated with prolonged survival. Based on the results of recent randomized controlled trials, HIPEC using oxaliplatin after CRS with shortened perfusion periods (30 minutes) is no longer recommended. There is a movement toward utilizing mitomycin C as a first-line intraperitoneal agent with extended perfusion times (90-120 minutes); however, there is currently little prospective evidence to support its widespread use.

Surgical outcomes in ileal Crohn's disease complicated by ileosigmoid fistula

BACKGROUND

The management of Crohn's disease (CD) complicated by ileosigmoid fistula (ISF) remains a challenge, and Australian outcomes have not previously been reported.

METHODS

A retrospective review of a tertiary colorectal inflammatory bowel disease unit, across public and private sites, from 2005 to 2023 to identify adult patients having undergone operative management of ISF.

RESULTS

Twenty-nine patients underwent surgery for ISF in the study period. Seventeen were male and the median age was 40 years. The pre-operative diagnosis of ISF was made in 76%, and patients were more likely to undergo resectional surgery if the pre-operative diagnosis was made endoscopically. Sixty-nine percent of cases were performed electively, with 76% completed laparoscopically with an 18.5% conversion rate to an open approach. The ISF was oversewn in three patients, repaired primarily in 14 patients, managed with segmental wedge resection in eight patients and resected via an anterior resection in four patients. The rate of stoma formation at the index procedure was 20.7% overall and 22% in patients being acutely managed with steroids. Emergent cases were more likely to be defunctioned with a stoma. Morbidity was 17.2% with a single anastomotic leak.

CONCLUSION

ISF in CD remains difficult to diagnose pre-operatively, but can be safely managed laparoscopically without formal resection, and with limited use of diverting stoma formation. The specific surgical approach to the sigmoid in ISF is difficult to pre-determine and often requires decisions to be made intra-operatively.

Transcatheter arterial embolization for small-bowel bleeding: technical and clinical outcomes and risk factors for early recurrent bleeding

Background

This study evaluated the technical and clinical outcomes of transcatheter arterial embolization (TAE) in patients with acute small-bowel bleeding (SBB) and aimed to identify potential risk factors for early recurrent bleeding after TAE.

Methods

Thirty-one patients with SBB managed with TAE between January 2006 and December 2021 were included. Technical and clinical success was defined as angiographic occlusion of the bleeding artery and disappearance of clinical or laboratory signs of persistent bleeding without major complications. Complications were classified according to the Society of Interventional Radiology's guidelines. Kaplan-Meier estimates assessed overall survival, and logistic regression models determined risk factors for clinical success and early rebleeding.

Results

Technical and clinical success were achieved in 30/31 (97%) and 19 (61%), respectively. Early recurrent bleeding was present in 9 (29%) patients, and was treated by repeat embolization in 4 patients, conversion to surgery in 4, and comfort therapy in 1 patient. TAE-related small bowel ischemia requiring surgery was found in 2 (6.5%) patients. Thirty-day and in-hospital mortality were 19% (6/31) and 23% (7/31), respectively; overall 5-year estimated survival was 60%. Thrombocytopenia and elevated prothrombin time (PT)/activated partial thromboplastin time (aPTT) levels prior to TAE were identified as risk factors for clinical failure (P=0.0026 and P=0.027, respectively), and for residual or early recurrent bleeding (P<0.001 and P=0.01, respectively).

Conclusions

TAE is safe and effective for managing severe SBB; however, early recurrent bleeding was found in nearly one third of patients. Thrombocytopenia and elevated PT/aPTT levels were risk factors for early recurrent bleeding.

Surgical and survival outcomes of early-onset colorectal cancer patients: a single-centre descriptive Australian study

BACKGROUND

Early-onset colorectal cancer (EOCRC) incidence is increasing in Australia. However, no Australian studies have reported on EOCRC patients' surgical management and survival patterns.

METHODS

A retrospective study of 111 EOCRC patients treated at the Royal Prince Alfred Hospital (RPAH), Sydney, Australia between January 2013 and December 2021 was performed. RPAH is a quaternary referral centre for pelvic exenteration (PE) and cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

RESULTS

Most patients had left-sided tumours (76.58%) and stage IV disease at the time of presentation (37.85%). 27.93% of patients underwent either CRS/HIPEC and PE and 72.07% of patients underwent other colorectal resections of which the most common was low anterior resection (19.82%). A stoma was fashioned in 50.54% of patients. Complications occurred in 54.95% of patients of which most were Clavien-Dindo grade II (47.54%). Absolute 1-, 3- and 5-year time intervals were 93.69%, 87.39% and 85.48%. Disease-free and overall survival were poorer in stage IV patients who had PE, followed by CRS/HIPEC then other colorectal resections (P < 0.001 and P = 0.003).

CONCLUSIONS

Stoma formation, PE and CRS/HIPEC and minor postoperative complications were common in our EOCRC cohort. Despite this, the 5-year absolute survival rate was acceptable. Thus, an aggressive surgical approach in EOCRC patients at a quaternary referral centre may be feasible at the cost of greater postoperative morbidity. This information is imperative in the surgical consent and preoperative counselling of EOCRC patients and highlights the need for further research to assess the postoperative functional outcomes and quality of life of EOCRC patients.

Clinical Work-Integrating Care in Current Practice: A Scoping Review

PURPOSE

Clinical work-integrating care (CWIC) refers to paying attention to work participation in a clinical setting. Working patients may benefit from CWIC. The purpose of this study is to explore the extent and nature to which medical specialists provide CWIC and what policies and guidelines oblige or recommend specialists to do.

METHODS

A scoping review was conducted. The databases MEDLINE, EMBASE, Psychinfo, CINAHL, and Web of Science were searched for studies on the extent and nature of CWIC and supplemented by gray literature on policies and guidelines. Six main categories were defined a priori. Applying a meta-aggregative approach, subcategories were subsequently defined using qualitative data. Next, quantitative findings were integrated into these subcategories. A separate narrative of policies and guidelines using the same main categories was constructed.

RESULTS

In total, 70 studies and 55 gray literature documents were included. The main findings per category were as follows: (1) collecting data on the occupation of patients varied widely; (2) most specialists did not routinely discuss work, but recent studies showed an increasing tendency to do so, which corresponds to recent policies and guidelines; (3) work-related advice ranged from general advice to patient-physician collaboration about work-related decisions; (4) CWIC was driven by legislation in many countries; (5) specialists sometimes collaborated in multidisciplinary teams to provide CWIC; and (6) medical guidelines regarding CWIC were generally not available.

CONCLUSION

Medical specialists provide a wide variety of CWIC ranging from assessing a patient's occupation to extensive collaboration with patients and other professionals to support work participation. Lack of medical guidelines could explain the variety of these practices.

Flavonoids and post haemorrhoidectomy recovery: a systematic review and meta-analysis

BACKGROUND

Haemorrhoidectomy is the gold standard for definitive treatment of high-grade symptomatic haemorrhoids but is often associated with substantial pain. This systematic review aims to explore the potential of flavonoids in alleviating the postoperative symptom burden following excisional haemorrhoidectomy.

METHODS

A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42023472711). Randomized controlled trials (RCTs) published PubMed, MEDLINE, Embase, and Scopus from inception to 1st December 2023 were retrieved. The primary outcome investigated was post-operative pain. Meta-analysis was performed using Review Manager version 5.4.1.

RESULTS

Ten articles with 775 patients were included. The meta-analysis identified statistically significant decreases in post-operative pain in favour of the flavonoid groups (Standardized Mean Difference -0.66 [95% confidence intervals (CI) -0.82, -0.52]; P < 0.00001), and bleeding (Odds Ratio 0.13 [95% CI 0.09, 0.19]; P < 0.00001).

CONCLUSION

Flavonoids show promise as a means of reducing pain associated with excisional haemorrhoidectomy. Further research is required to investigate topical routes of administration and standardize regimes.