Circumferential resection margin positivity due to direct or indirect tumour involvement in rectal cancer - a call for better stratification

BACKGROUND

A positive circumferential resection margin (CRM) after rectal cancer surgery, which can be the result of direct or indirect tumour involvement, has consistently been associated with increased local recurrence and poorer survival. However, little is known of the differential impact of the mode of tumour involvement on outcomes.

METHODS

1460 consecutive patients undergoing rectal cancer resection between 2003 and 2018 were retrospectively assessed. Histopathology reports for patients with a positive CRM were reviewed to determine cases of direct (R1-tumour) or indirect tumour involvement (R1-other). Disease-free survival (DFS) and overall survival (OS) were assessed by Kaplan-Meier analysis. The role of the mode of CRM positivity was examined by univariate and multivariate Cox proportional hazards models.

RESULTS

Eighty-five patients had an R1 resection due to CRM involvement (5.8%). Of those, 69 were due to direct tumour involvement, while 16 were from indirect causes. Kaplan-Meier analysis revealed that R1-other was associated with increased OS (hazard ratio 0.40, log-rank P = 0.006) and DFS (P = 0.043). Multivariate regression confirmed that the mode of CRM positivity was an independent predictor of OS. More interestingly, the patterns of recurrence were different between the two groups, with R1-tumour leading to significantly more local recurrence (P = 0.04).

CONCLUSIONS

Our data strongly suggests that direct tumour involvement of the CRM confers worse prognosis after rectal cancer surgery. Importantly, differences in the site and frequency of recurrences make a case for better stratification of patients with a positive CRM to guide treatment decisions.

Outcomes of surgery in patients aged ≥90 years in the general surgical setting

Introduction An increasing proportion of the population is living into their nineties and beyond. These high risk patients are now presenting more frequently to both elective and emergency surgical services. There is limited research looking at outcomes of general surgical procedures in nonagenarians and centenarians to guide surgeons assessing these cases. Methods A retrospective analysis was conducted of all patients aged ≥90 years undergoing elective and emergency general surgical procedures at a tertiary care facility between 2009 and 2015. Vascular, breast and endocrine procedures were excluded. Patient demographics and characteristics were collated. Primary outcomes were 30-day and 90-day mortality rates. The impact of ASA (American Society of Anesthesiologists) grade, operation severity and emergency presentation was assessed using multivariate analysis. Results Overall, 161 patients (58 elective, 103 emergency) were identified for inclusion in the study. The mean patient age was 92.8 years (range: 90-106 years). The 90-day mortality rates were 5.2% and 19.4% for elective and emergency procedures respectively (p=0.013). The median survival was 29 and 19 months respectively (p=0.001). Emergency and major gastrointestinal operations were associated with a significant increase in mortality. Patients undergoing emergency major colonic or upper gastrointestinal surgery had a 90-day mortality rate of 53.8%. Conclusions The risk for patients aged over 90 years having an elective procedure differs significantly in the short term from those having emergency surgery. In selected cases, elective surgery carries an acceptable mortality risk. Emergency surgery is associated with a significantly increased risk of death, particularly after major gastrointestinal resections.

Extended pelvic side wall excision for locally advanced rectal cancers

Extended pelvic side wall excision is a useful technique for treatment of recurrent or advanced rectal cancer involving sciatic notch and does not compromise the dissection of major pelvic vessels and vascular control.

Anatomical differentiation of direct and indirect inguinal hernias: Is it worthwhile in the modern era?

The study aimed to assess the clinical accuracy of differentiating direct and indirect inguinal hernias preoperatively by different grades of surgeons. A retrospective audit was conducted over a 9-year period and comprised all adult inguinal hernia patients operated by one consultant surgeon. The hernias were differentiated into direct and indirect hernias based on the direction of cough impulse and the deep ring occlusion test. The preoperative diagnosis was compared with intraoperative findings. During the study period, 503 patients were examined. Of these, 272 patients were diagnosed as having indirect hernias and 56 patients as having direct hernias. In 175 patients, no attempt was made to differentiate indirect and direct hernias. When compared with intraoperative findings, the diagnosis was correct in 77% of the indirect hernias and 55% of direct hernias. Of the patients in whom no differentiation was attempted, 115 patients had indirect hernias, 56 had direct hernias, and four had both. For indirect hernias, the diagnostic accuracy was 82, 63, and 30% for consultant, registrars, and senior house officers. For direct hernias, the diagnostic accuracy was 66, 50, and 44%, respectively. This study demonstrates relatively poor accuracy in diagnosing direct inguinal hernias regardless of seniority.

Road rage and road traffic accidents among commercial vehicle drivers in Lahore, Pakistan

Road rage and road traffic accidents increase the burden of morbidity and mortality in a population. A cross-sectional survey with convenience sampling was conducted among commercial vehicle drivers in Lahore, Pakistan (n = 901) to record their behaviours/experiences regarding road rage and road traffic accidents. Respondents were asked about incidents of shouting/cursing/rude gestures or threats to physically hurt the person/vehicle, by others or themselves, in the previous 24 hours or 3 months, and their involvement in road traffic accidents in the previous 12 months. Auto-rickshaw drivers were significantly more likely to report various road rage experiences/behaviours and involvement in accidents compared with bus and wagon drivers. A total of 112 respondents (12.4%) reported being involved in a road traffic accident in the previous 12 months but traffic police did not record the accident in 52.7% of cases. The results of this study underline the need to improve road safety in Pakistan.

Road rage behaviour and experiences of rickshaw drivers in Rawalpindi, Pakistan

A cross-sectional survey with convenience sampling was conducted among rickshaw drivers in Rawalpindi, Pakistan to study their road rage behaviour and experiences. Cumulatively 318 male drivers participated in this study. The most common forms of road rage reported were: having been shouted at; and having experienced rude gestures from other drivers (78.9% each). Least common forms of road rage reported were: threats of physical hurt or having actually been physically hurt ( < or = 3% each). Rickshaw drivers with shorter driving time (< or = 10 years) had significantly more road rage experiences than those who had been driving for more than 10 years (P < 0.01). There is a need for nationally representative surveys to study road age in commercial vehicle drivers so as to improve road safety in Pakistan.

A 5-year analysis of readmissions following elective laparoscopic cholecystectomy - cohort study

AIMS

This study aimed to determine readmission rates, causes for readmission and outcomes for patients undergoing elective Laparoscopic Cholecystectomy (LC) without intraoperative cholangiogram (IOC).

METHODS

Timing related to readmissions was grouped as <6 weeks, 6 weeks-1 year, 1-2 years and >2 years. Outcomes and variables related to readmission were evaluated.

RESULTS

101 readmissions (6.6) were noted amongst 1523 consecutive LC. The median follow up was 4 years (range 1.6-6.4 years). There was no difference in the median age (48 vs. 53 years, P = 0.2) and sex of the patients between the readmitted and no readmission groups. The incidence of readmissions (n = 101) within the first 6 weeks, 6 weeks-1 year, 1-2 years and >2 years were 2.8%, 1.5%, 1.4% and 0.7% respectively. The most common reasons for readmissions were non-specific abdominal pain (NSAP) (36%), obstructive jaundice (14%), peptic ulcer disease (10%), intra-abdominal collection (4%) and bile leak (3%), pancreatitis (3%), and other reasons (30%). Overall, 24 (22%) of readmissions were related to biliary problems, the majority of these occurred (15/24, 63%) within 6 weeks of LC. The incidence of retained stones within the first 6 weeks, 6 weeks-1 year, 1-2 years and >2 years were 0.4%, 0.3%, 0.1% and 0% respectively. Overall 14 (14%) patients were readmitted with retained stones and all were managed by ERCP & ductal clearance.

CONCLUSIONS

Readmission rate following elective LC is low with the majority occurring within the first 6 weeks and only a quarter of these related are directly to biliary pathology. In the absence of routine IOC, around 1% of patients present with retained stones within 2 years of LC. A small fraction of patients continue to suffer from NSAP and should be warned prior to the surgery.

Use of topical negative pressure in assisted abdominal closure does not lead to high incidence of enteric fistulae

AIM

Reports suggested an increase in enterocutaneous fistulae with topical negative pressure (TNP) use in the open abdomen. The purpose of this study was to establish if our experience raises similar concerns.

METHOD

This is a 5-year prospective analysis, from January 2004 to December 2008, of 42 patients who developed deep wound dehiscence or their abdomen was left open at laparotomy requiring 'TNP' to assist in their management. The decision to use TNP was taken if it was felt unwise or not feasible to close the abdomen.

RESULTS

There were 22 men; the median age was 68 (range 21-88) years. Twenty of 42 patients had peritonitis, 5/42 had oedematous bowel, 5/42 ischaemic gut, one had a large abdominal wall defect following debridement due to methicillin-resistant staphyloccus (MRSA) infection, 11/42 developed deep wound dehiscence. In 30/42, VAC abdominal dressing system and TNP were applied. In 12/42, VAC GranuFoam and TNP were used, of these five patients required a mesh to control the oedematous bowel. Four of 42 patients died. A total of 34 patients had anastomotic lines, 2/42 developed enteric fistulae, and both survived.

CONCLUSION

This study does not support the reports suggesting a higher fistulae rate with TNP. In our opinion, its use in the open abdomen is safe.

Topical negative pressure in managing severe peritonitis: A positive contribution?

AIM: To assess the use of topical negative pressure (TNP) in the management of severe peritonitis.

METHODS: This is a four-year prospective analysis from January 2005 to December 2008 of 20 patients requiring TNP following laparotomy for severe peritonitis.

RESULTS: There were 11 males with an average age of (59.3 ± 3.95) years. Nine had a perforated viscus, five had anastomotic leaks, three had iatrogenic bowel injury, and a further three had severe pelvic inflammatory disease. TNP and the VAC^® Abdominal Dressing System were initially used. These were changed every two to three days. Abdominal closure was achieved in 15/20 patients within 4.53 ± 1.64 d. One patient required relaparotomy due to residual sepsis. Two patients with severe faecal peritonitis due to perforated diverticular disease received primary anastomosis at second look laparotomy, as sepsis and their general condition improved. In the remaining 5/20 cases, the abdomen was left open due to bowel oedema and or abdominal wall oedema. Dressing was switched to TNP and VAC^® GranuFoam^®. Three of the five patients returned a few months later for abdominal wall reconstruction and restoration of intestinal continuity. Two patients developed intestinal fistulae. All 20 patients survived.

CONCLUSION: The use of TNP is safe. Further studies are needed to assess its value in managing these difficult cases.

An unusual presentation of sclerosing mesenteritis as pneumoperitoneum: Case report with a review of the literature

Sclerosing mesenteritis is a rare condition that involves the small or large bowel mesentery. An unusual presentation of this condition, which led to difficult preoperative assessment and diagnosis, is described. This report is followed by a comprehensive review of the literature.

Gallstone ileus: surgical strategies and clinical outcome

OBJECTIVE

Gallstone ileus is a rare cause of intestinal obstruction affecting mainly the elderly. This study aimed to analyze the surgical treatments and outcome of the disease.

METHODS

We present a retrospective study of 13 patients diagnosed with gallstone ileus from January 2000 to December 2005 in our hospital and a review of the published literature.

RESULTS

Three men and 10 women participated in the study, with a mean age of 74.3 (range: 63-85). The mean duration of symptoms was 6 days (range 2-14). A pre operative diagnosis was made in 10 patients. The mean delay in diagnosis was 3.5 days (range 1-10). Ten patients had an enterolithotomy (E) and three patients had a one-stage procedure comprising enterolithotomy, cholecystectomy and fistula repair (EC). There was no postoperative mortality in either group. The mean postoperative hospital stay for group E was 14 (range 6-31) days and for group EC was 19 (range: 5-28) days. Twelve patients were alive at the time of review. One patient from group E died of unrelated causes after three years. One patient in group E developed cholangitis but no surgical intervention was required on case note review over a mean postoperative period of 3.4 years.

CONCLUSION

E alone is best suited in all elderly gallstone ileus patients with significant comorbidities. A one-stage procedure (EC) should be reserved for young, fit and low risk patients.

Emergency preparedness and humanitarian action: the research deficit. Eastern Mediterranean Region perspective

The WHO Eastern Mediterranean Region, extending from Morocco in the west to Pakistan in the east, with a population exceeding 490 million, suffers a large proportion of both natural and man-made disasters. Humanitarian partners in the health sector have played a major role in averting the excessive mortality and morbidity in response to previous emergencies; nevertheless much remains to be done to provide the evidence through rigorous research methods to standardize other essential elements of the health response to humanitarian emergencies. Strengthening of academic institutions, prioritization of research, financial resources and linkages with institutions in the developed world can ameliorate the situation in the Region.

Progression of electroclinical changes in complex partial status epilepticus: filling in the blanks

Treiman has described five electroclinical stages through which the EEG progresses during generalized convulsive status epilepticus (GCSE). The EEG can show similar patterns in patients with complex partial status epilepticus (CPSE), but there is no agreement as to whether the different patterns seen in the human EEG result from a similar orderly progression through similar stages. We report the case of a patient in CPSE whose EEG passed progressively through two of the earlier stages described by Treiman. This case of EEG progression in a single patient suggests that CPSE can progress through stages analogous to those in GCSE.

Streptonigrin. 1. Structure-activity relationships among simple bicyclic analogues. Rate dependence of DNA degradation on quinone reduction potential

A series of simple aza and diaza bicyclic quinones related to the AB ring system of streptonigrin (1) have been synthesized and tested in vitro for their ability to degrade DNA under conditions similar to those used with the parent drug. The results obtained from a study of 22 quinones indicate that there is a quantitative linear relationship between their reduction potentials and the rate at which they degrade DNA under identical conditions in vitro. Almost all of the synthetic substances were superior to 1 in their DNA-degrading ability.