Long-term mental and physical quality of life outcomes following ileal pouch anal anastomosis surgery

INTRODUCTION

This study presents the authors' experience over 14 years of performing restorative procto-colectomy with ileal pouch anal anastomosis (IPAA). The aim was to study the long-term quality of life outcomes and analyse the predictors of pouch function as well as physical and mental wellbeing.

METHODS

This is a single-centre retrospective study conducted in a specialised colorectal surgery unit in the UK. The study included patients who underwent two- or three-staged panproctocolectomy with defunctioning ileostomy for ulcerative colitis (UC) or familial adenomatous polyposis between 2004 and 2018. Data were collected from a prospectively, surgeon-maintained database. Pouch function and quality of life scores were obtained via validated questionnaires. A multivariate analysis was utilised to explore predictors of quality of life and pouch function.

RESULTS

The study reports 105 patients who underwent IPAA with a covering ileostomy. The majority of operations were performed for UC (97, 92.4%). The median age of patients was 36 years and the male to female ratio was 1:1. Thirty patients (28.5%) suffered early post-IPAA complications, while pouch failure rate was 11.4% (12/105). Late complications were reported at a rate of 45%. On long-term follow-up, the median Pouch Function Score was 7 (IQR 3-14). Both the physical and mental sections of the quality of life score were at a median indistinguishable from the normal population but had different predictors associated with them.

CONCLUSION

Our findings recognise the complex interplay between physical and psychological wellbeing after pouch surgery and advise psychological counselling where appropriate.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Right ventricular outflow tract reintervention after primary tetralogy of Fallot repair in neonates and young infants

OBJECTIVE

To assess the outcomes following primary tetralogy of Fallot (TOF) repair in neonates and young infants with pulmonary stenosis (PS) and pulmonary atresia and compare differences in reintervention on the right ventricular outflow tract (RVOT) among those undergoing valve sparing repair (VSR), transannular RVOT patch (TAP), and right ventricle-to-pulmonary artery (RV-PA) conduit surgeries.

METHODS

Data were collected retrospectively in 101 patients who underwent TOF repair over a 10-year period between January 2005 and September 2015. The primary endpoint was reintervention on the RVOT, defined as a surgical procedure or cardiac catheterization-based RVOT reintervention.

RESULTS

Forty-three patients had TOF/PS, of whom 24 (56%) underwent TAP and 19 (44%) underwent VSR. Fifty-eight patients had TOF/PA, 14 (24%) underwent TAP and 44 (76%) underwent RV-PA conduit repair. Overall patient mortality was 2.9% (3 of 101). Thirty-three patients underwent surgical reintervention, and 52 underwent catheterization-based reintervention. Patients with TOF/PA who underwent RV-PA conduit repair had a higher surgical reintervention rate than those who underwent TAP (45% vs 21%). Patients with TOF/PSs undergoing VSR with a lower median birth weight (2.5 kg vs 3.7 kg) required more surgical reintervention.

CONCLUSIONS

Neonatal TOF repair can be performed with low mortality but frequent RVOT reinterventions. Surgical reintervention is earlier and the rate is higher among patients with TOF/PA undergoing RV-PA conduit repair compared with those undergoing TAP. Although there were no overall differences in RVOT reintervention rate between patients with TOF/PS undergoing VSR and those undergoing TAP, a lower birth weight in the patients undergoing VSR is associated with a higher surgical reintervention rate.

Anomalous Aortic Origin of a Coronary Artery: Symptoms Do Not Correlate With Intramural Length or Ostial Diameter

Background:

Anomalous aortic origin of a coronary artery (AAOCA) is a known cause of sudden death. Our hypothesis was that longer intramural length and smaller ostial diameter correlate with preoperative symptoms. If true, this would assist in the decision for surgical indications. We also assessed the accuracy of preoperative imaging to predict intramural length.

Methods:

Retrospective analysis of patients who underwent AAOCA unroofing from 2006 to 2014. Patients had preoperative computed tomography angiography (CTA) or magnetic resonance imaging (MRI). Intramural length was measured. Intramural lengths and ostial diameters were also measured intraoperatively (operating room [OR]). Symptoms were noted. Intramural lengths and ostial diameters were compared between patients with and without preoperative symptoms. The accuracy of intramural length measured by CTA/MRI versus the length measured in the OR was assessed using a Bland-Altman analysis.

Results:

Sixty-six patients underwent surgical repair of AAOCA. Fifty-two (79%) patients were symptomatic and 14 (21%) were asymptomatic. Mean age was 12.4 ± 4.0 years. There was no mortality. There was strong agreement between intramural length measured by CTA/MRI and measured in the OR. There was no significant difference in AAOCA intramural length in the symptomatic (8.6 ± 3.5 mm) and asymptomatic (8.9 ± 2.8 mm, P = .77) patients, which were measured both by CTA/MRI and intraoperatively (symptomatic 7.3 ± 2.5 mm, asymptomatic 6.9 ± 2.8 mm; P = .62). There was also no significant difference in AAOCA ostial diameters between groups (symptomatic = 1.9 ± 0.5 mm, asymptomatic = 1.6 ± 0.5 mm; P = .09).

Conclusion:

Preoperative CTA/MRI was very accurate in predicting the length of surgical unroofing. There was no demonstrable correlation between preoperative symptoms and intramural AAOCA length or AAOCA ostial diameter.

Ocular Manifestations in Patients with HIV Infection/AIDS who were Referred from the ART Centre, Hassan, Karnataka, India

BACKGROUND

Ocular involvement in HIV infection/AIDS is very common and it includes various clinical presentations which may be asymptomatic or atypical or they may be the initial manifestations of the underlying disease. The severity of these lesions increases as the immune competency decreases, leading to visual impairment or blindness.

OBJECTIVE

The purpose of this study was to determine the prevalence and the types of HIV associated ocular conditions and their effect on the vision in patients with HIV/AIDS.

METHODS

This cross sectional study was based on the patients with HIV infection/AIDS, who were referred to the Ophthalmic OPD, District hospital, Hassan. These patients were referred from the District ART Centre for a complete ophthalmic evaluation, irrespective of their immune status and the presence or absence of symptoms. All the patients underwent a complete ophthalmic examination, which included both anterior and posterior segment evaluation and colour vision assessment.

RESULTS

Out of the 553 patients, 66% belonged to the age group of 21-40 years. 87% of the patients had a BCVA of >6/18, whereas 4.7% had very poor vision. 37.6% of the patients had ocular manifestations. Anterior segment, posterior segment and neuro-ophthalmic manifestations were seen in 7%, 9.94% and 5.79% of the patients respectively. The most common anterior segment manifestation was recurrent lid infections, while HIV microangiopathy was the most common posterior segment manifestation. The other unusual findings included an abnormal colour vision in 6.3% of the patients and bilateral lid retraction in 8.5% of the patients.

CONCLUSION

Since ocular manifestations are very common and as they can occur at any time during the course of HIV infection, an awareness on various patterns of the ocular disease and the screening of all the patients with HIV infection/AIDS is a must.

Beneficial Effects of Humidified, Warmed Carbon Dioxide Insufflation during Laparoscopic Bariatric Surgery: a Randomized Clinical Trial

BACKGROUND

Recent data has shown that the use of warmed, humidified carbon dioxide (CO2) insufflation during laparoscopic surgery may be associated with better outcomes.

METHODS

We performed a randomized, doubleblind, prospective controlled clinical trial of 30 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Patients were randomized into 2 groups. The first group (group 1, n=15) received standard (dry, room temperature) CO2 for insufflation during the surgery, while the second group (group 2, n=15) received warmed (35 degrees C) and humidified (95%) CO2. Patients received postoperative analgesia from morphine delivered via a patient-controlled analgesia (PCA) pump. Pain scores (on a scale of 0 to 10, 0 being no pain and 10 being the worst pain) were measured postoperatively at 3 h, 6 h, 1 day and 2 days. The amount of morphine that was delivered through the PCA was also measured at the same time intervals. Operating-room (OR) time, core temperature, and total hospital length of stay were documented.

RESULTS

Postoperative pain as documented by pain scores and narcotic usage were not statistically different in the 2 groups. We demonstrated a statistically significant difference (mean+/-SD) in OR time (76+/-16 min vs 101+/-34 min, P=0.02), total hospital length of stay (3.2+/-.4 days vs 4.0+/-.9 days, P=0.01) and end-of-case core temperature (36.2+/-.5 degrees C vs 35.7+/-.6 degrees C, P=0.02) in group 2 compared with group 1.

CONCLUSION

The use of warmed, humidified CO2 insufflation in bariatric patients undergoing LRYGBP was not associated with any significant benefit with regards to postoperative pain.