Operative trends following the adoption of nonoperative management of rectal cancer

BACKGROUND

Differentiating clinical near-complete and complete responses (cCR) after neoadjuvant therapy (NT) is challenging in rectal cancer patients. We hypothesized that magnetic resonance imaging staging limitations for low rectal cancers may increase the proportion of abdominoperineal resection (APR) with permanent colostomy for those without a cCR.

METHODS

Single institution retrospective analysis of rectal cancer cases before and after adoption of nonoperative "watch and wait" (W&W) pathway. APR as a percentage of rectal resections was the primary outcome.

RESULTS

There were 76 total mesorectal excisions (TME) in the pre-W&W group and 98 in the post-W&W group. NT was significantly more common in the post-W&W group. There was no significant difference in the APR primary outcome (pre-W&W APR 33.3% vs. post-W&W APR 26.5%, p = 0.482). APR patients had fewer complete TME grades (69.2% vs. 46.2%) and more pathologic complete responses (0% vs. 26.9%) in the post-W&W period. The cCR rate for patients with nonoperative management was 51.4% (n = 37) and 13.5% (n = 5) had regrowths, all of whom underwent salvage surgery.

CONCLUSION

APR for those without a cCR to NT has not increased in the nonoperative management era. Balancing the pathologic complete response rate may require restaging some patients with clinical near-complete responses.

Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy

OBJECTIVE

To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence.

BACKGROUND

While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks.

METHODS

Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014).

RESULTS

Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%].

CONCLUSIONS

Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.

Thirty years of the health care service for ostomy patients in Juiz de Fora and surroundings

OBJECTIVE

to establish the epidemiological profile of ostomized patients treated at the Health Care Service for Ostomy Patients in Juiz de Fora and region (SASPO/JF) and to quantify the pathologies that led to the stoma as well as the ostomy-related complications.

METHOD

a retrospective study was carried out with the analysis of 496 medical records of patients registered at HCSOP/JF over 30 years and who remained in at the service in June 2018. The following variables were considered: age, sex, pathology that led to the stoma, type, time, location and complications of stomas.

RESULTS

53.43% were male patients and 46.57% female. The average age was 56.24 years among men and 58.40 years among women. Eight patients had two types of ostomies simultaneously and a total of 504 ostomies were as follows: 340 colostomies (67.46%), 117 ileostomies (23.21%) and 47 urostomies (9.33%). Additionally, 47.65% of the colostomies and 76.92% of the ileostomies were temporary, while all urostomies were permanent. In 70.24% of cases, the reason for making the stoma was malignancy. There were 277 stomas with one or more complications (54.96%).

CONCLUSIONS

most of the ostomized patients were over 50 years old and the main diagnosis that led to the stoma was malignancy. Ileostomies had a higher percentage of complications than colostomies and urostomies and, for all types of stomas, the most frequent complication was dermatitis.

Clinicopathological characteristics and outcomes of metachronous rectal cancer in patients with a history of cervical cancer with and without remote radiotherapy: Reports of 45 cases

The purpose of this study was to report the clinicopathological characteristics and treatment outcomes of 45 rectal cancer patients who have a history of cervical cancer with or without remote radiotherapy. Twenty-nine patients (64.4%) with a history of cervical cancer treated with pelvic radiotherapy were classified as group A, 16 (35.6%) patients with a history of cervical cancer not treated with radiotherapy were classified as group B. The median duration between radiotherapy for cervical cancer and rectal adenocarcinoma diagnosis was 18 years. At the time of rectal cancer diagnosis, 5 (17.2%) patients presented stage I disease, 15 (51.7%) had stage II, 1 (3.4%) had stage III, and 8 (27.6%) had stage IV. The patients in group A had older age, higher rates of gross ulcerative lesions, low hemoglobin levels, and a lower rate of lymph node metastases. The patients with secondary rectal cancer developed after radiotherapy for cervical cancer usually presented with abnormal abdominal symptoms, such as proctitis, cystitis, or rectal fistula. Higher colostomy rate was found in this group of patients due to severe pelvic fibrosis or proctitis.

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

BACKGROUND

End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection.

METHODS

This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.

RESULTS

In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001).

CONCLUSION

Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013-2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88-6.69) (OR: 11.24; 95% CI: 8.53-13.95), more time spent in ICU (2.73; 1.70-3.76) (7.98; 6.10-9.87), and increased risk for surgical site infection (1.32; 1.03-1.68) (2.54; 1.71-3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study)

BACKGROUND

Laparoscopic lavage was proposed in the 1990s to treat purulent peritonitis in patients with perforated acute diverticulitis. Prospective randomized trials had mixed results. The aim of this study was to determine the success rate of laparoscopic lavage in sepsis control and to identify a group of patients that could potentially benefit from this treatment.

METHODS

This retrospective multicentre international study included consecutive patients from 24 centres who underwent laparoscopic lavage from 2005 to 2015.

RESULTS

A total of 404 patients were included, 231 of whom had Hinchey III acute diverticulitis. Sepsis control was achieved in 172 patients (74·5 per cent), and was associated with lower Mannheim Peritonitis Index score and ASA grade, no evidence of free perforation, absence of extensive adhesiolysis and previous episodes of diverticulitis. The operation was immediately converted to open surgery in 19 patients. Among 212 patients who underwent laparoscopic lavage, the morbidity rate was 33·0 per cent; the reoperation rate was 13·7 per cent and the 30-day mortality rate 1·9 per cent. Twenty-one patients required readmission for early complications, of whom 11 underwent further surgery and one died. Of the 172 patients discharged uneventfully after laparoscopic lavage, a recurrent episode of acute diverticulitis was registered in 46 (26·7 per cent), at a mean of 11 (range 2-108) months. Relapse was associated with younger age, female sex and previous episodes of acute diverticulitis.

CONCLUSION

Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.

Surgical Intervention for Right-Side Diverticulitis: A Case-Matched Comparison with Left-Side Diverticulitis

Right-side diverticulitis (RSD) is an uncommon disease in Western countries. We conducted a case-matched comparison of surgically managed right-side and left-side diverticulitis (LSD) from the Southern California Kaiser Permanente database (2007-2014). Of 995 patients undergoing emergent surgery for diverticulitis, 33 RSD (3.3%) met our inclusion criteria and were matched (1:1) to LSD based on age, gender, year of diagnosis, and Hinchey class. Mean age of the RSD group was 56 ± 13.9 years, and 24.2 per cent were Asian. RSD was classified as Hinchey class III or IV in 28.1 per cent and 9.4 per cent of cases, respectively. Right hemicolectomy was performed in 87.9 per cent and laparoscopy was used in 24.2 per cent of the cases. Surgically managed RSD patients were more likely to be Asian (25% vs 3.1%, P = 0.03) and have body mass index < 25 (31.3% vs 6.3%, P = 0.02) compared with LSD patients. Diverting stoma was less common in the RSD (6.3% vs 62.5%) (P < 0.001). Hospital stay was shorter in RSD (7.6 ± 4.2 vs 12.8 ± 9.4 days, P = 0.006) and more common in the RSD group (P < 0.01). Open surgery (90.6% vs 71.9%) and postoperative complications (37.5% vs 25%) were more common in the LSD group, but that was not statistically significant (P > 0.05). Surgery for complicated RSD was associated with shorter hospital stay and decreased likelihood of diverting ostomy.

Systematic review of outcome measures following chemoradiotherapy for the treatment of anal cancer (CORMAC)

AIM

Six Phase III randomized trials have determined the effectiveness of chemoradiotherapy as primary treatment for anal squamous cell carcinoma (ASCC), but outcomes reported in these trials varied widely, hindering evidence synthesis. To improve reporting in all future trials, we aim to develop a core outcomes set (COS). As the first stage of COS development, we undertook a systematic review to summarize the outcomes reported in studies evaluating chemoradiotherapy for ASCC.

METHOD

Systematic literature searches identified studies evaluating radiotherapy or chemoradiotherapy for ASCC. Outcomes and accompanying definitions were extracted verbatim and categorized into domains.

RESULTS

From 5170 abstracts, we identified 95 eligible studies, reporting 1192 outcomes and 533 unique terms. We collapsed these terms into 86 standardized outcomes and five domains: survival; disease activity; life impact [including quality of life (QoL)]; delivery of care; and toxicity. The most commonly reported domains were survival and disease activity, reported in 74 (86%) and 54 (62%) studies, respectively. No outcome was reported in every publication. Over half (43/86) of the standardized outcome terms were reported in fewer than five studies, and 21 (25%) were reported in a single study only. There was wide variation in definitions of disease-free survival, colostomy-free survival and progression-free survival (PFS). Anal continence was reported in only 35 (41%) studies.

CONCLUSION

Outcomes reported in studies evaluating chemoradiotherapy for ASCC were heterogenous and definitions varied widely. Outcomes likely to be important to patients, such as ano-rectal function, toxicity and QoL, have been neglected. A COS for future trials will address these issues.

Hartmann's procedure, reversal and rate of stoma-free survival

Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.

Traumatic colorectal injuries in children: The National Trauma Database experience

PURPOSE

We sought to utilize a nationwide database to characterize colorectal injuries in pediatric trauma.

METHODS

The National Trauma Database (NTDB) was queried for all patients (age≤14years) with colorectal injuries from 2013 to 2014. We stratified patients by demographics and measured outcomes. We analyzed groups based on mechanism, colon vs rectal injury, as well as colostomy creation. Statistical analysis was conducted using t-test and ANOVA for continuous variables as well as chi-square for continuous variables.

RESULTS

There were 534 pediatric patients who sustained colorectal trauma. The mean ISS was 15.6±0.6 with an average LOS of 8.5±0.5days. 435 (81.5%) were injured by blunt mechanism while 99 (18.5%) were injured by penetrating mechanism. There were no differences between age, ISS, complications, mortality, LOS, ICU LOS, and ventilator days between blunt and penetrating groups. Significantly more patients in the penetrating group had associated small intestine and hepatic injuries as well as underwent colostomies. Patients with rectal injuries (25.7%) were more likely to undergo colonic diversion (p<0.0001), but also had decreased mortality (p=0.001) and decreased LOS (p=0.01). Patients with colostomies (9.9%) had no differences in age, ISS, GCS, transfusion of blood products, and complications compared to patients who did not receive a colostomy. Despite this, colostomy patients had significantly increased hospital LOS (12.1±1.8 vs 8.2±0.5days, p=0.02) and ICU LOS (9.0±1.7 vs 5.4±0.3days, p=0.02).

CONCLUSION

Although infrequent, colorectal injuries in children are associated with considerable morbidity regardless of mechanism and may be managed without fecal diversion.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Epidemiology.

Outcome of emergency surgery for severe neuroleptic-induced colitis: results of a prospective cohort

AIM

The study evaluated the outcome of severe acute antipsychotic (neuroleptic) drug related colitis requiring emergency surgery.

METHOD

From 2009 to 2014, 20 patients underwent emergency surgery for acute and severe neuroleptic-related ischaemic colitis. Neuroleptic-induced colitis was defined as another cause besides inflammatory, infectious or ischaemic colitis with a relationship to treatment by antipsychotic drugs.

RESULTS

The main drugs involved were cyamemazine (n = 9, 45%), loxapine (n = 5, 25%), haloperidol (n = 4, 20%) and alimemazine (n = 4, 20%). Most (n = 14, 70%) patients presented with haemodynamic instability requiring massive resuscitation and vasopressive drugs. CT signs of digestive impairment were found in 13 (65%) patients having emergency surgery. The lesions were pancolonic in 40%; transparietal necrosis was found in 45% and 15% had colonic perforation. Twelve (60%) patients had total or subtotal colectomy and eight (40%) a segmental colectomy with colostomy or ileostomy in all cases. The postoperative mortality was 15% and morbidity was 70%, necessitating surgical reintervention in two (10%) patients. Of the 17 surviving patients, 11 (64.7%) had restoration of intestinal continuity after a median delay of 103 days, with a postoperative morbidity rate of 36.3%. In the intent-to-treat population, the permanent stoma rate was 30%.

CONCLUSION

The morbidity and mortality of surgery for neuroleptic-drug-induced colitis is higher than for colitis due to other causes. A better knowledge of this condition should lead to early diagnosis.

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis

Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.

Postoperative outcomes in patients with perforated bowel: early versus late intervention

BACKGROUND

Time to intervention is suggested to be a crucial factor for a number of surgical conditions. In this study, we aim to examine the postoperative outcomes associated with the timing of surgical intervention in patients with perforated bowel.

MATERIALS AND METHODS

Cross-sectional study using the Nationwide Inpatient Sample database, 2003-2010. The study population included adult (≥18 y) inpatients who had perforated intestine or colon and underwent bowel surgery.

RESULTS

A total of 5412 (64.6%) patients who had an early surgical intervention on same day of admission and 2985 (35.4%) patients who had a delayed surgery were included. Patients with comorbidities or those in hospitals in the Northeast region of the United States were more likely to have a delayed intervention (P < 0.01). In low-risk patients who are aged <65 y old and with no comorbidities, the timing of surgery did not associate with the risk of postoperative complications (P = 0.77) and mortality (P = 0.08), whereas in high-risk patients who are aged ≥65 y old or with comorbidities, an early surgical intervention was associated with a lower risk of complications (odds ratio: 0.77; 95% CI: 0.69-0.87; P < 0.001), and a lower mortality risk (odds ratio: 0.79; 95% CI: 0.68-0.92; P = 0.002). Patients with a delayed intervention were associated with a hospital stay >15 d (P < 0.001) and a higher cost of health services (P < 0.01).

CONCLUSIONS

Patients treated in the Northeast of the United States were more likely to experience a delayed surgery. Delay of surgical intervention is associated with unfavorable outcomes only in older patients or those with comorbidities.

[Intestinal stomas. Are they as simple as they seem?]

OBJECTIVES

To examine the morbidity and mortality of the formation and closure of enterostomies.

METHODS

Retrospective study between 2000-2014 of patients younger than 14 years old who underwent an enterostomy. We evaluated: surgical technique, underlying pathology, general and stoma complications, sex, age and weight at the time of formation. At the closure we evaluated: surgical technique, age, weight, hemoglobin, hematocrit and albumin, as well as complications.

RESULTS

We performed 120 enterostomies in 114 patients: 69 (57.5%) colostomies, 43 (35.8%) ileostomies and 8 (6.7%) yeyunostomy. The most frequent causes were: anorectal malformation (45/69), necrotizing enterocolitis (24/43) and intestinal atresia (4/8) respectively. 39 (32.5%) complications related to the stoma (colostomy 21, Ileostomy 15, Yeyunostomy 3; p= 0.845), 11 (9.2%) required surgery (colostomy 8, Ileostomy 2, Yeyunostomy 1; p= 0.439), and 17 (14.2%) general complications (colostomy 9, Ileostomy 7, Yeyunostomy 1; p= 0.884). We found a higher rate of complications requiring surgery in loop enterostomy 8/38 (21.1%), separated 3/54 (5.3%) or double-barrel 0/25 (p= 0.007). We closed 96 (80%), presenting complications in 14; yeyunostomy 4/6 (66.7%), colostomies 5/59 (8.5%), ileostomies 5/31 (16.1%) (p= 0.001). Hematocrit and hemoglobin below age average, and albumin under normal values are associated with complications when closing enterostomies (p< 0.05). Six patients (25%) who didn't went to closure died as a result of the underlying pathology and 5 (20.8%) of other causes.

CONCLUSION

The formation and closing of enterostomies remains a procedure with a high rate of complications. However, there are no clear risk factors, excepting the use of loop enterostomy and lower albumin, hemoglobin or hematocrit at the time of closure.

Longterm -ostomy as a quality marker: Comparison of outcomes from a six year series of laparoscopic surgery in MRI defined low rectal cancer

AIM

We propose long-term -ostomy rate following laparoscopic rectal cancer resection must be included as an overall quality indicator of treatment in conjunction with frequently reported and readily available end points.

METHOD

A database was collated prospectively of consecutive rectal cancer resections over a 6-year period. Recorded data included pre-operative MRI (tumour stage and height from the anal-verge), as well as demographics, treatment, local recurrence rate, survival and -ostomy rate as the primary outcome measure.

RESULTS

65 patients were identified and classified as low-rectal cancer if the tumour on MRI was < 6 cm from the anal verge or middle/upper-rectal cancer if between 6 and 15 cm from the anal-verge and below the peritoneal reflection. Permanent stoma rates including colostomies and non-reversed ileostomies were 31.7% for middle/upper rectal cancer; 62.5% for low-rectal cancer and an overall rate of 42.1% for all rectal cancers. For upper-rectal cancer the rates of local recurrence, predicted mortality, R0 resection and conversion were: 0%, 1.9%, 97.6% and 0% respectively. Corresponding figures for low-rectal cancer were: 4.2%, 2.7%, 95.8% and 0%. There were no significant differences for age, sex, predicted morbidity/mortality, survival, recurrence or leak rates between the groups.

CONCLUSION

Laparoscopic rectal cancer surgery has a comparable permanent -ostomy rate to open rectal cancer surgery. We benchmark 31.7% as the permanent -ostomy rate for upper-rectal cancer and 62.5% for low-rectal cancer following laparoscopic resection, in the context of 96.9% R0 resection and 0% conversion rate in a consecutive series of patients.

Anastomotic leaks after colorectal anastomosis occurring more than 30 days postoperatively: a single-institution evaluation

National hospital registries only report colorectal anastomotic leaks (ALs) within 30 days postoperatively. The aim of our study was to determine the incidence and significance of ALs that occur beyond 30 days postoperatively. We performed a retrospective review of our prospective database from June 2008 to August 2012. A total of 504 patients were included. These patients were operated on by two surgeons. Any clinical or radiographic abnormalities were considered to be an anastomotic imperfection. A total of 504 patients were reviewed with a total of 18 (3.6%) anastomotic leaks. Six leaks (31.6% of leaks) were diagnosed more than 30 days postoperatively (P < 0.001). Of the 18 leaks, interventional radiology drainage was performed for four cases and 14 patients required reoperation. All six delayed leaks required reoperation. There was one leak that occurred under 30 days, which was discovered on autopsy. The median follow-up was 12 months (range, 1 to 4 months). All the delayed leak patients presented with fistulas, whereas 58 per cent of typical leak patients presented with the triad of leukocytosis, fever, and abdominal pain. Colorectal anastomotic leaks can occur after the 30-day postoperative period. In patients with vague and atypical abdominal findings, anastomotic leak must be suspected. More systematic, prospective studies are required to help us further understand the risk factors and natural history of anastomotic failures in elective colorectal surgery.

Tumour- and treatment-related colostomy rates following mitomycin C or cisplatin chemoradiation with or without maintenance chemotherapy in squamous cell carcinoma of the anus in the ACT II trial

BACKGROUND

Squamous cell carcinoma of the anus (SCCA) is highly sensitive to chemoradiation (CRT) which achieves good loco-regional control and preserves anal function. However, some patients require permanent stoma formation either as a result of surgery on relapse, poor anal function or treatment-related symptoms. Our aim was to determine patient, tumour and treatment-related colostomy rates following CRT and maintenance chemotherapy in the ACT II trial.

PATIENTS AND METHODS

The ACT II trial recruited 940 patients comparing 5FU-based CRT using cisplatin (CisP) or mitomycin C (MMC) with or without additional maintenance chemotherapy. We investigated the association between colostomy-free survival (CFS) and progression-free survival (PFS) with age, gender, T-stage, N-stage, treatment and baseline haemoglobin.

RESULTS

The median follow-up was 5.1 years (n = 884 evaluable/940); tumour site canal (84%), margin (14%); stage T1/T2 (52%), T3/T4 (46%); N+ (32%), N0 (62%). Twenty out of 118 (17%) colostomies fashioned before CRT were reversed within 8 months. One hundred and twelve patients had a post-treatment colostomy due to persistent disease (98) or morbidity (14). Fifty-two per cent (61/118) of all pre-treatment colostomies were never reversed. The 5-year CFS rates were 68% MMC/Maint, 70% CisP/Maint, 68% MMC/No-maint and 65% CisP/No-maint. CRT with CisP did not improve CFS when compared with MMC (hazard ratio: 1.04, 95% confidence interval: 0.82-1.31, P = 0.74). The 5-year CFS rates were higher for T1/T2 (79%) than T3/T4 (54%) tumours and higher for node-negative (72%) than node-positive (60%) patients. Significant predictors of CFS were gender, T-stage and haemoglobin, while treatment factors had no impact on outcome. Similar associations were found between PFS and tumour/treatment-related factors.

CONCLUSIONS

The majority (52%) of pre-treatment colostomies were never reversed. Neither CRT with 5FU/CisP nor maintenance chemotherapy impacted on CFS. The low risk of colostomy for late effects (1.7%) is likely to be associated with the modest total radiotherapy dose. The predictive factors for CFS were T-stage, gender and baseline haemoglobin.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN 26715889.

Failing to reverse a diverting stoma after lower anterior resection of rectal cancer

BACKGROUND

A diverting stoma is an accepted adjunct to low anterior resection (LAR) for rectal cancer. However, some patients do not undergo a subsequent procedure to have the stoma reversed. We aim to determine incidence and risk factors for nonclosure of the diverting stoma.

METHODS

This is a retrospective study of stage I to III rectal cancer patients at a single institution having LAR with curative intent and a diverting stoma.

RESULTS

We studied 162 patients. Prevalence of nonclosure of the temporary stoma was 14.5% within 13 months of the index surgery. On a multivariate linear regression model, nonclosure was associated with anastomotic leak (odds ratio 9.89, 2.31 to 43.93, P < .001) and age older than 65 (odds ratio 2.76, 1.08 to 7.48, P < .036).

CONCLUSIONS

Prevalence of nonclosure of a diverting stoma after LAR for rectal cancer is substantial (14.5%). Patients should be counselled regarding this risk with particular attention to potential risk factors.

Traumatic colon injuries -- factors that influence surgical management

BACKGROUND

This study sought to evaluate current trends in surgical management of colon injuries in a level I urban trauma centre, in the light of our increasing confidence in primary repair.

METHODS

Our retrospective study evaluates the results of 116 patients with colon injuries operated at Bucharest Clinical Emergency Hospital, in the light of some of the most commonly cited factors which could influence the surgeon decision-making process towards primary repair or colostomy.

RESULTS

Blunt injuries were more common than penetrating injuries (65% vs. 31%). Significant other injuries occurred in 85 (73%) patients. Primary repair was performed in 95 patients (82%). Fecal diversion was used in 21 patients(18%). Multiple factors influence the decision-making process: shock, fecal contamination, associated injuries and higher scores on the Abdominal Trauma Index (ATI) and Colon Injury Scale (CIS). Colon related intra-abdominal complications occurred in 7% of patients in whom the colon injury was closed primarily and in 14% of patients in whom a stoma was created, ATI having a predictive role in their occurrence. The overall mortality rate was 19%.

CONCLUSIONS

Primary repair of colon injuries, either by primary suture or resection and anastomosis, is a safe method in the management of the majority of colonic injuries. Colostomy is preferred for patients with ATI ≥ 30 and CIS ≥ 4. Surgical judgment remains the final arbiter in decision making.

Unexpected rectal cancer after TEM: outcome of completion surgery compared with primary TME

BACKGROUND

Transanal endoscopic microsurgery (TEM) has gained wide-spread acceptance as a safe and useful technique for the resection of rectal adenomas and selected T1 malignant lesions. If the lesion appears >T1 rectal cancer after resection with TEM, a completion TME resection is recommended. The aim of this study was to investigate the results of TME surgery after TEM for rectal cancer.

METHODS

In four tertiary referral hospitals for TEM, all patients with completion TME surgery after initial TEM were selected. All eligible patients who were treated with 5 × 5 Gy radiotherapy followed by TME surgery from the Dutch TME trial were selected as reference group. A multivariate logistic regression model was used to calculate odds ratio's (OR) for colostomies and for colo- and ileostomies combined. Local recurrence and survival rates were compared in hazard ratio's (HR) using the multivariate Cox proportional hazard model.

RESULTS

Fifty-nine patients were included in the TEM-COMPLETION group and 881 patients from the TME trial. In the TEM-COMPLETION group, 50.8% of the patients had a colostomy compared to 45.9% in the TME trial, OR 2.51 (p < 0.006). There is no significant difference when ileo- and colostomies are analyzed together. In the TEM-COMPLETION group, 10.2% developed a local recurrence compared to 5.2% in the TME trial, HR 6.8 (p < 0.0001).

CONCLUSIONS

Completion TME surgery after TEM for unexpected rectal adenocarcinoma results in more colostomies and higher local recurrence rates compared to one stage TME surgery preceded with preoperative 5 × 5 Gy radiotherapy. Pre-operative investigations must be optimized to distinguish malignant and benign lesions and prevent avoidable local recurrence and colostomies.

Sphincter-preserving surgery for rectal cancer: a population-based study in Taiwan

BACKGROUND/AIMS

Sphincter-preserving surgery (SPS) has been considered a surrogate for surgical quality for rectal cancer. This study aims to assess its rate for rectal cancer between centers and over time in Taiwan.

METHODOLOGY

Data from 1997 to 2006 on patients undergoing sphincter-preserving surgery (anterior resection or AR) and proctectomy with colostomy (abdominoperineal resection or APR) were extracted from a national health insurance database. Hierarchical logistic regression was used to identify independent factors associated with SPS.

RESULTS

Data on 19,919 patients were analyzed. Among them, 12,164 (61%) received AR and 7,755 (39%) underwent APR at total of 115 centers. Multifactorial analysis revealed higher SPS rates with female gender (p<0.001) and patients paying higher insurance premiums (p=0.005). Higher APR rates were seen in those receiving surgery at metropolitan hospitals (p=0.001) and hospitals outside higher volume regions (Taipei City and North, p≦0.005). For hospitals with initial low surgical volumes, significant improvement of SPS rate was found (p<0.001) with increasing volume over the study period.

CONCLUSIONS

The disparity due to sphincter loss in rectal cancer between hospitals of various regions and levels narrowed in Taiwan. Characteristics of hospital (level, region, volume) and patient (gender, premium level) influenced SPS rate.

Correlation in rectal cancer between clinical tumor response after neoadjuvant radiotherapy and sphincter or organ preservation: 10-year results of the Lyon R 96-02 randomized trial

PURPOSE

To investigate, in rectal cancer, the benefit of a neoadjuvant radiation dose escalation with endocavitary contact radiotherapy (CXRT) in addition to external beam radiotherapy (EBRT). This article provides an update of the Lyon R96-02 Phase III trial.

METHODS AND MATERIALS

A total of 88 patients with T2 to T3 carcinoma of the lower rectum were randomly assigned to neoadjuvant EBRT 39 Gy in 13 fractions (43 patients) vs. the same EBRT with CXRT boost, 85 Gy in three fractions (45 patients). Median follow-up was 132 months.

RESULTS

The 10-year cumulated rate of permanent colostomy (CRPC) was 63% in the EBRT group vs. 29% in the EBRT+CXRT group (p < 0.001). The 10-year rate of local recurrence was 15% vs. 10% (p = 0.69); 10-year disease-free survival was 54% vs. 53% (p = 0.99); and 10-year overall survival was 56% vs. 55% (p = 0.85). Data of clinical response (CR) were available for 78 patients (36 in the EBRT group and 42 in the EBRT+CXRT group): 12 patients were in complete CR (1 patient vs. 11 patients), 53 patients had a CR ≥ 50% (24 patients vs. 29 patients), and 13 patients had a CR <50% (11 patients vs. 2 patients) (p < 0.001). Of the 65 patients with CR ≥ 50%, 9 had an organ preservation procedure (meaning no rectal resection) taking advantage of major CR. The 10-year CRPC was 17% for patients with complete CR, 42% for patients with CR ≥ 50%, and 77% for patients with CR <50% (p = 0.014).

CONCLUSION

In cancer of the lower rectum, CXRT increases the complete CR, turning in a significantly higher rate of long-term permanent sphincter and organ preservation.

Factors affecting morbidity in penetrating rectal injuries: a civilian experience

BACKGROUND

The principles of the treatment of rectal injuries have been determined based on the experiences gained from military injuries. While adopting these principles in civilian life, it is essential to know the characteristics of civilian rectal injuries as well as the risk factors affecting morbidity.

METHODS

The characteristics of 29 inpatients who had been treated due to rectal injuries caused by gunshot wounds and penetrating devices were evaluated. In order to determine the risk factors, the patients were divided into two groups regarding the presence of morbidity (Group 1, with morbidity; Group 2, without morbidity) and compared.

RESULTS

Severe fecal contamination, perianal or gluteal injuries, duration of trauma- treatment interval, and isolated extraperitoneal injury were significant factors that affected the development of morbidity. The length of hospital stay was significantly longer in Group 1 as compared to Group 2.

CONCLUSION

Although rectal injuries are rarely encountered, they carry high morbidity and mortality. Awareness of the risk factors and planning of a patient-based treatment are essential for the success of the therapy. The rate of morbidity is substantially decreased when patients are treated in time. Thus, the awareness of both patients as well as physicians managing trauma about rectal injuries should be increased.

Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis

BACKGROUND

The use of a colonic stent as a bridge to surgery aims to provide patients with elective one-stage surgical resection while reducing stoma creation and postoperative complications. This study used meta-analytic techniques to compare the outcomes of stent use as a bridge to surgery and emergency surgery in the management of obstructive colorectal cancer.

METHODS

A literature search of Medline, Embase, Cochrane controlled trials registry, and the Chinese Biomedical Literature Database was performed on all studies comparing stent as a bridge to surgery and emergency surgery for obstructive colorectal cancer. A meta-analysis of the included studies was carried out to identify the differences in outcomes between the two procedures.

RESULTS

Eight studies matched the criteria for inclusion and reported on the outcomes of 601 patients, of whom 232 (38.6%) underwent stent insertion and 369 (61.4%) underwent emergency surgery. Fewer patients in the stent group needed intensive care (risk ratio [RR], 0.42; 95% confidence interval [CI], 0.19-0.93; p = 0.03) and stoma creation (RR, 0.70; 95% CI, 0.50-0.99; p = 0.04). The primary anastomosis rate in the stent group was higher (RR, 1.62; 95% CI, 1.21-2.16; p = 0.001). Overall complications (RR, 0.42; 95% CI, 0.24-0.71; p = 0.001), including anastomotic leakage (RR, 0.31; 95% CI, 0.14-0.69; p = 0.004), were reduced by stent insertion. Stent placement before elective surgery did not adversely affect mortality and long-term survival.

CONCLUSIONS

The use of a stent as a bridge to surgery for obstructive left-sided colorectal cancer could increase the chance of primary anastomosis and reduce the need for stoma creation and postprocedural complications. Stent insertion before subsequent surgery has no effect on perioperative mortality and long-term survival.

Application of a tertiary referral scoring system to predict nonreversal of Hartmann's procedure for diverticulitis in a community hospital

Riansuwan et al. at Cleveland Clinic developed a scoring system to quantify the risk of Hartmann's nonreversal based on age, preoperative transfusion, pulmonary comorbidity, American Society of Anesthesiologists score, perforation, and anticoagulation. Our study validates the scoring system in a community hospital setting. Patients undergoing Hartmann's procedure for diverticulitis (2006 to June 2009) were identified from our hospital's database. Two groups were formed based on Hartmann's reversal within 1 year and those with nonreversal. An independent-sample t test and logistic regression using score and nine other variables as predictors of Hartmann's nonreversal were run. Sixty-three of 93 patients (67.7%) had a Hartmann's reversal. Higher scores and higher mean age were seen in the nonreversal group (15.5 ± 3.0 vs 12.1 ± 2.5 and 73 ± 15 vs 63 ± 14 years, respectively). Patients with scores 18 or above were not reversed; 43 of 49 patients (88%) with scores of 13 or less were reversed. Logistic regression confirmed that the only predictive variable for nonreversal is a higher score. The scoring system is predictive of nonreversibility of Hartmann's procedure for acute diverticulitis. This will be useful in allowing surgeons to strategize accurately and to counsel patients realistically. Higher scores may allow both the surgeon and patient to have a low threshold for exploring alternatives to Hartmann's procedure.

[Stoma use in the general surgery service of CHU Gabriel Touré]

OBJECTIVES

Were to determine the frequency, to describe the clinical and therapeutic aspects digestive stoma.

MATERIAL AND METHODS

It was about six months an exploratory study from January 1st to June 30th, 2008 in the department of surgery general of the CHU Gabriel Touré. Were included in this study all the patients carrying a enter stoma or a colostomy, old of more than 15 ans. The digestive dents, the other types of stoma and the patients old of less than 15 years, were excluded. The results were analyzed by the software Epi information version 6.4 Fr, the tests of Khi 2 and Student with a threshold of significance for P < 0.05.

RESULTS

We college 32 patients are 7.4% of all digestive surgical operations, 13.3% of the abdominal urgencies; composed of 26 men (81.25%) and 6 women (18.75%). The sex ratio at summer of 4.3. The average age was 44, 8 years with a standard deviation 8, 13 and the extremes varying between 16-80 years. Twenty and one (65.6%) sick were operated in urgency. We carried out 29 cases (90.6%) of final stoma, 3 cas (9.4%) side, 21 cas (65.6%) of colostomy, 9 cas (28.1%) of ileostomies. They were temporary in 25 cas (78.1%) and final 7 cas (21.9%). The volvulus of the sigmoid colonist with necroses 10 cas (31.3%), the peritonitis by typhus perforation ilea 9 cas (28.1%), occlusions on tumor of the left colonist 8 cas (25%), the traumatic perforations ileales 2 cas (6.3%), the digestive dents post appendicectomies 2 cas (6.3%) and the congenital megacolon 1 cas (3%) was the indications of the stoma. the operational continuations were simple in 21 cas (65.6%). The principal found complications were: coetaneous irritation 7 cas (21.8%), the prolapsed stomiale 4 cas (12.5%), the suppuration peristomial 3 cas (9.4%), the releasing of Stoma 3 cas (9.4%), the retraction of the stoma 3 cas (9.4%),the psychological disorders 3 cases (9.4%), the hemorrhage 2 cas (6.3), necroses peristomial 2 cas (3.1%), septic shock 2 cas (6.3%), and 1 cas (3.1%) of evisceration, obstruction of the bowels, shock hypovolemic. The intermediate duration of hospitalization was of 37,5 jours with a standard deviation = 13.58 and extremes varying between 02-73 days. Death rate was of 9.4%.

CONCLUSION

The assumption of responsibility of the stomies is difficult in the absence of stomatherapeutes, and of the high cost of the parenteral nutrition in our context .

Treatment of anal carcinoma in immune-compromised patients

BACKGROUND

Immune-compromised populations show an increased incidence of anogenital tract neoplasms. This study was undertaken to evaluate local control (LC), overall survival (OS) and toxicity in immune-compromised patients with anal carcinoma treated with radiotherapy with or without chemotherapy.

METHODS

We identified 25 patients with anal carcinoma and human immunodeficiency virus (HIV) infection or history of solid-organ transplant on chronic medical immune-suppression. Median age and follow-up were 44 years and 26 months respectively. AJCC T-stages were Tis (4%), T1 (8%), T2 (58%) and T3 (29%). N-stages were N0 (79%), N1 (4%), N2 (13%) and N3 (4%). One patient had metastatic disease at diagnosis. Seventy-five percent received concurrent chemoradiotherapy. Median radiation dose to the primary tumour was 50 Gy.

RESULTS

One-, 3- and 5-year LC without salvage therapy was 87%, 87% and 70% respectively. One-, 3- and 5-year actuarial OS was 96%, 73% and 61% respectively. One-, 3- and 5-year OS was 100% for treatment time (TT) <50 days and 57%, 38% and 0% for TT > or =50 days (p=0.0009). All patients had acute grade 2-3 skin toxicity. Acute grade 3-4 gastrointestinal (GI), genitourinary (GU) and haematological toxicity occurred in 8%, 0% and 38%. Late grade 3-4 skin, GI and GU toxicity occurred in 8%, 4% and 0%.

CONCLUSIONS

Most HIV-positive and organ transplant patients receiving radiotherapy with or without chemotherapy experience acute toxicity but few have chronic complications. T-stage and CD4 level in HIV-positive patients predict for LC. T-stage and TT predict for OS.

An exploratory analysis of the epidemiology and surgical management of perforated diverticular disease over a two-year period at a referral centre in the Caribbean

OBJECTIVE

We present an exploratory analysis of data collected on perforated diverticular disease (PDD) in Barbados and suggest possible areas for further study.

SUBJECTS AND METHODS

All cases of perforated diverticular disease treated at the Queen Elizabeth Hospital (QEH) Barbados, between January 1, 2005 and December 31, 2006 were reviewed. The patient's age, gender location of disease, Hinchey stage, operative procedure, rate of colostomy reversal, length of hospitalization, incidence of peri-operative morbidity and postoperative mortality were analysed using principal components analysis (PCA).

RESULTS

Fourteen cases of PDD were treated at the QEH during this period. Six (43%) of the patients had perforated right-sided diverticulitis (PRSD). In the PCA, Dimensions 1 and 2 were the two dimensions examined, as they both had Eigenvalues over 1. Dimension 1 can be taken as an indicator of the intensity of the disease. On dimension 2, length of hospitalization had the highest component loading (0.875). The mean hospital stay was 10.6 days in PRSD, 9.5 in left-sided perforations with primary anastomosis, and 16.2 days for those with a Hartmann's procedure. The overall peri-operative morbidity was 28% and there was no mortality in the series.

CONCLUSION

This preliminary study seems to show a relatively high incidence of PRSD in a predominantly Afro-Caribbean population. More research is needed to determine the exact aetiology of this disease. In our experience, primary anastomosis in carefully selected patients with either PRSD or perforated left-sided diverticulitis (PLSD) may result in shorter hospitalization.

Diverticulitis in California from 1995 to 2006: increased rates of treatment for younger patients

Colonic diverticular disease is responsible for over 300,000 admissions and expenditures exceeding $2.7 billion/year. There is recent evidence that rates of treatment for diverticulitis have increased in the United States over the last decade. We hypothesize that these national trends of increasing rates of hospitalizations for diverticulitis would be found in an analysis of a single-state discharge database. Data from the Office of Statewide Health Planning and Development were used to analyze treatment for diverticulitis in California from 1995 to 2006. For each hospitalization, surgical care was determined based on procedure codes for left colon resection and/or colostomy. Overall numbers of admissions for acute diverticulitis increased throughout the 12-year study period with an estimated annual percentage of change (EAPC) of 2.1 per cent (P < 0.001). Rates of admissions increased most rapidly in patients 20 to 34-years-old (EAPC = 8.6%, P < 0.001) and 35 to 49 years old (EAPC = 5.7%, P < 0.001). Elective colectomies had an EAPC of 2.1 per cent (P < 0.001), which was also most dramatic in younger age groups. Between 1995 and 2006 we found significant increases in both the rates of hospitalization for diverticulitis and rates of elective surgical treatment in California. These increases are entirely due to higher rates of care for younger patients.

Primary closure in colon trauma

BACKGROUND

Primary repair of colon injuries is an accepted therapeutic option; however, controversy persists regarding its safety. Our objective was to report the evolution and presence of complications in patients with colon injury who underwent primary closure and to determine if the time interval (>6 h), degree of injury, contamination, anatomic site injured, PATI (Penetrating Abdominal Trauma Index) >25, and the presence of other injuries in colon trauma are associated with increased morbidity and mortality.

METHODS

This was a prospective, observational, longitudinal and descriptive study conducted at the Central Hospital "Dr. Ignacio Morones Prieto," San Luis Potosí, Mexico, from January 1, 2003 to December 31, 2007. We included patients with abdominal trauma with colon injury subjected to surgical treatment. chi(2) was used for basic statistical analysis.

RESULTS

There were 481 patients with abdominal trauma who underwent surgery; 77(16.1%) had colon injury. Ninety percent (n = 69) were treated in the first 6 h; 91% (n = 70) were due to penetrating injuries, and gunshot wound accounted for 48% (n = 37). Transverse colon was the most frequently injured (38%) (n = 29). Grade I and II injuries accounted for 75.3% (n = 58). Procedures included primary repair (76.66 %) (n = 46); resection with anastomosis (8.3%) (n = 5); and colostomy (15%) (n = 9). Associated injuries were present in 76.6% (n = 59). There was some degree of contamination in 85.7% (n = 66); 82.8% (58) had PATI <25. Complications associated with the surgical procedure were observed in 28.57% (n = 22). Reoperation was necessary in 10% (n = 8). Average hospital stay was 11.4 days. Mortality was 3.8% (n = 3); none of these were related to colon injury.

CONCLUSIONS

Primary repair is a safe procedure for treatment of colon injuries. Patients with primary repair had lower morbidity (p <0.009). Surgery during the first 6 h (p <0.006) and in hemodynamically stable patients (p <0.014) had a lower risk of complications.

Primary repair vs. colostomy in colon injuries

BACKGROUND

Colon trauma is frequent and its prevalence is difficult to establish because of the different factors that intervene in its origin. In Mexico, traumatic colon injuries, albeit stab wounds or gunshot wounds, are on the rise. Our objective was to evaluate the most appropriate management for traumatic colon injuries.

METHODS

We conducted a retrospective study of 178 case files of patients with abdominal trauma and colon lesions during a 5-year period from January 2003 to June 2008 from the General Hospital of Balbuena, Mexico City. The study compared the use of primary closure vs. colostomy, analyzing variables such as sex, age, type of wound, severity of lesion and mortality.

RESULTS

There were a total of 178 patients; 156 were male (87.6%) and 22 were female (12.4%). The most affected age group was between 21 and 30 years; 74 patients (41.6%) had stab wounds and 104 patients (58.4%) had gunshot wounds. Management consisted mainly of primary closure in 92 cases (51.7%) vs. colostomy in 86 patients (48.3%). However, 64% of gunshot wounds were treated with colostomy. Reported mortality was 9.55% and this was due to different factors such as multiple organ injury.

CONCLUSIONS

Treatment of traumatic colon injury should be case specific, taking into account the mechanism of the lesion, its severity and associated injuries.

The influence of smoking and other risk factors on the outcome after radiochemotherapy for anal cancer

BACKGROUND

Smoking is an important risk factor for the development of cancer. Smoking during radiochemotherapy therapy may have a negative influence on prognosis. We evaluated the effect of smoking during radiochemotherapy on the outcome for patients with anal cancer.

METHODS

Sixty-eight patients (34 smokers, 34 non-smokers) treated by radiochemotherapy for anal cancer were analysed. The effect of smoking during radiochemotherapy and other risk factors (gender, T- and N category, tumor site, dose, therapy protocol) on disease-specific survival (DSS), local control (LC) and colostomy free survival (CFS) was evaluated.

RESULTS

There was a significant difference in age and male:female ratio between the two groups. With a median follow up of 22 months (max. 119) DSS, LC, and CFS were 88%, 84% and 84%. A significant difference in local control between smokers (S) and non-smokers (NS) was found (S 74% vs. NS 94%, p = .03). For DSS and CFS a difference in terms of outcome between smokers and non-smokers was seen (DSS: S 82% vs. NS 96%, p = .19, CFS: S 75% vs. 91%, p = .15), which did not reach statistical significance. In multivariate analyses only gender had a significant association with LC and T category with CFS. The other risk factors did not reach statistical significance.

CONCLUSION

Even though our evaluation reached statistical significance only in univariate analysis, we suggest, that the role of smoking during radiochemotherapy for anal cancer should not be ignored. The potential negative effect on prognosis should be explained to patients before therapy.

The VA Ostomy Health-Related Quality of Life Study: objectives, methods, and patient sample

OBJECTIVE

To present the design and methods of a multisite study of health-related quality of life (HR-QOL) in veterans living with ostomies.

RESEARCH DESIGN AND METHODS

Veterans from Tucson, Indianapolis, and Los Angeles VA Medical Centers were surveyed using the validated City of Hope ostomy-specific tool (mCOH-QOL-Ostomy) and the SF-36V. Cases (ostomates) had a major gastrointestinal procedure that required an intestinal stoma, while controls had similar procedures for which an ostomy was not required. Ostomy subjects were recruited for four focus groups in each of two sites divided by ostomy type (colostomy versus ileostomy) and overall mCOH-QOL-Ostomy HR-QOL score (highest versus lowest quartile). The focus groups further evaluated barriers, concerns, and adaptation methods and skills.

MAIN OUTCOME MEASURES

This report presents recruitment results, reliability of survey instruments, and demographic characteristics of the sample.

RESULTS

The overall response (i.e., recruitment) rate across all sites was 48% and by site was 53%, 57%, and 37%, respectively (p < 0.001). Internal consistency reliability estimates indicated that both instruments remain reliable in this population (Cronbach's alpha for HR-QOL domains/scales: 0.71-0.96). Cases and controls were similar in demographic characteristics. Proportions of minority subjects matched projections from the site patient populations. Subjects with ostomies had significantly longer time since surgery than controls (p < 0.001). Focus groups were comprised of two to six subjects per group and demonstrated racial diversity at the Los Angeles site.

CONCLUSIONS

The unique design of our study of VA patients with ostomies is an illustration of a successful mixed methods approach to HR-QOL research. We collected meaningful quantitative and qualitative data that will be used in the development of new approaches to care that will lead to improved functioning and well-being in persons living with ostomies. Subsequent reports will provide the results of this research project.

Temporal changes in the management of diverticulitis

PURPOSE

This study was designed to evaluate temporal trends in the use and type of operative and non-operative interventions in the management of diverticulitis.

METHODS

A retrospective cohort using a statewide administrative database was used to identify all patients hospitalized for diverticulitis in the state of Washington (1987-2001). Poisson and logistic regression were used to calculate changes in the frequency of hospitalization, operative and percutaneous interventions, and colostomy over time.

RESULTS

Of the 25,058 patients hospitalized non-electively with diverticulitis (mean age 69 +/- 16, 60% female) there were only minimal changes in the frequency of admissions over time (0.006% increase per year-IRR 1.00006 95% CI 1.00004, 1.00008). The odds of an emergency colectomy at initial hospitalization decreased by 2% each year (OR 0.98 95% CI 0.98, 0.99) whereas the odds of percutaneous abscess drainage increased 7% per year (OR 1.07 95% CI 1.05, 1.1). Among patients undergoing percutaneous drainage, the odds of operative interventions decreased by 9% compared to patients who did not have a percutaneous intervention (OR 0.91 95% CI 0.87, 0.94). The proportion of patients undergoing colostomy during emergency operations remained essentially stable over time (range 49-61%), as did the proportion of patients undergoing prophylactic colectomy after initial non-surgical management (approximately 10%).

CONCLUSIONS

There was a minimal increase in the frequency of diverticulitis admissions over time. A rise in percutaneous drainage procedures was associated with a decrease in emergency operative interventions. The proportion of patients undergoing colostomy remained stable, and there does not seem to be a significant increase in the use of one-stage procedures for diverticulitis.

Neonatal short bowel syndrome: a cohort study

BACKGROUND

To date, our knowledge of morbidity and mortality in neonatal short bowel syndrome (SBS) is based on individual case series. Shortcomings of the published literature include long patient recruitment time, selection bias, variable SBS definitions, failure to account for gestational age, and incomplete follow-up. By applying more rigorous methodology, our aim was to determine outcomes of SBS neonates compared with a control group of neonates without SBS.

METHODS

A cohort study of all neonates with abdominal pathology requiring laparotomy between January 1, 1997, and December 31, 1998, with observation through July 1, 2001. Short bowel syndrome was defined as patients requiring parenteral nutrition for more than 42 days or residual small bowel length of less than 25% predicted by gestational age. Student's t test, Mann-Whitney U test, and chi2 were used where appropriate. Kaplan-Meier curves were used to determine cumulative survival. Covariates important in the development of SBS were examined using forward step-wise logistic regression.

RESULTS

There were 175 patients (with SBS = 40, without SBS = 135) with a mean gestational age of 30.7 +/- 4.6 weeks vs 35.9 +/- 4.8 weeks, respectively (P < .0005). The patients with SBS suffered significantly more morbidity than the group without SBS in all categories of investigation (surgical complications, septic events, central venous line complications, duration to adaptation and parenteral nutrition independence, cholestasis and liver failure, and duration of hospitalization). The case fatality rate was 37.5% in patients with SBS vs 13.3% in patients without SBS (P = .001). Most of the deaths were caused by liver failure or sepsis and occurred within 1 year from the date of surgery. Presence of an ileostomy (exp(B) = 12.29; P < .0005) and a residual small bowel length less than 50% of the original length (exp(B) = 26.84; P < .0005) were the only 2 variables in a logistic regression analysis found to be independently associated with the development of SBS.

CONCLUSION

This cohort study clearly illustrates the tremendous morbidity experienced by infants with SBS relative to other surgical neonates. Accurate estimates of the morbidity associated with SBS enables clinicians to appropriately counsel parents, allocate resources and initiate therapeutic trials.

A ten-year study of penetrating injuries of the colon

BACKGROUND

Colon injury has been associated with a high risk of septic complications and mortality. We prospectively studied the pattern, management, outcome, and prognostic factors in patients who sustained penetrating colon injuries.

PATIENTS AND METHODS

Sixty patients who presented to our hospital with penetrating colon injuries over a ten-year period (1992 to 2001) were studied.

RESULTS

Colon wounds were caused by gunshots in 55 (91.7 percent) patients and knife stabs in 5 (8.3 percent). There was a delay of more than 12 hours before laparotomy in 30 (50 percent) patients. Moderate or major fecal contamination of the peritoneal cavity occurred in 58 (96.7 percent) patients. The average penetrating abdominal trauma index score was 25.9 and 20 (33.3 percent) patients sustained Flint Grade 3 colon injury. Associated intra-abdominal injuries occurred in the small bowel (73.3 percent), liver (25 percent), stomach (23.3 percent), and mesentery (16.7 percent). Right colon wounds (35) were managed by primary repair in 24 (68.6 percent) patients and proximal diverting colostomy in 11 (31.4 percent), whereas left colon wounds (25) were managed by diverting colostomy in 22 (88.0 percent) patients and primary repair in 3 (12.0 percent) patients. Common complications included wound infection (56.7 percent), septicemia (31.7 percent), and enterocutaneous fistula (16.7 percent). The overall mortality rate was 33.3 percent and colon injury-related mortality was 21.7 percent. Presence of destructive colon injury was associated with a greater than fourfold increased incidence of death. Other significant risk factors included shock on admission, major fecal contamination, duration of operation more than four hours, penetrating abdominal trauma index score >25, and more than two postoperative complications. There was no difference in outcome between patients who had primary repair and those undergoing diverting colostomy. Colostomy closure-related morbidity was 21 percent and mortality was 5.3 percent.

CONCLUSION

A more liberal use of primary repair is required in our patients with penetrating injuries of the colon.

What proportion of patients with an ostomy (for diverticulitis) get reversed?

A common operation for patients with complicated sigmoid diverticulitis is resection and placement of an ostomy (Hartmann procedure). This population-based study examines that proportion of ostomates who undergo reversal. In the California inpatient file, patients admitted for acute diverticulitis in 1995 were identified, including a subset that had surgical resection. Data regarding receipt of ostomy were obtained (4-year follow-up). Demographics and clinical data (procedure, ostomy reversal, time to reversal, comorbidity score, and complications) were collected. In 1995, 11,582 admissions for diverticulitis occurred in California. Of these, 24.2 per cent (n = 2808) underwent surgery at admission; 88.9 per cent were sigmoid/left colectomies; and 41.7 per cent had a Hartmann procedure. Patients with ostomies were older (P = 0.0004) and male (P = 0.03). Median comobidity score was the same for patients with or without an ostomy. Of the 1176 patients who had the Hartmann procedure, 65 per cent underwent reversal (mean 143 days). A larger proportion of men than women had their ostomies reversed (74.5% vs 55.9%, respectively, P < 0.0001). Median comorbidity scores for both groups were low, 0 for those reversed and 1 for nonreversed. Our study shows that although the majority of patients had their ostomies reversed, over 35 per cent did not at 4-year follow-up. Further studies are required to evaluate how this rate may be improved.

Morbidity and mortality of colostomy and its closure in children

BACKGROUND

This study evaluated the complications of colostomy and its closure in infants and children.

METHODS

One hundred forty-six colostomies were performed in 86 neonates, 23 infants, and 37 children older than 1 year. These children underwent colostomies for anorectal malformation (84), Hirschsprung's disease (47), and other miscellaneous (15) conditions like colonic atresia, volvulus, rectal tuberculosis, traumatic rectal perforation, and intestinal obstruction caused by ascariasis.

RESULTS

Of these, 17 (11.6%) had early complications, and 80 (69.8%) had stomal complications. Three patients died, but only 1 death was directly related to colostomy. Colostomy prolapse, peristomal excoriation, and malnutrition were the major complications. The complications were not dependant on the children's age or primary indication. Sigmoid colostomy had a lower malnutrition rate than transverse colostomy (34.9% v 16.9% P =.009). Among the 56 children who underwent colostomy closure, major complications include death (1.8%), anastomotic leak (7.1%), and wound infection (12.6%).

CONCLUSIONS

A divided sigmoid colostomy should be performed whenever possible. Proper stomal care, regular nutritional assessment, and early closure of the colostomy would minimize morbidity and mortality of colostomy and its closure.

Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures

INTRODUCTION

The benefits of the laparoscopic approach to colon and rectal surgery do not seem as great as for other laparoscopic procedures. To study this further we decided to review the current literature and the 10-year experience of a surgical group from university teaching hospitals in Montréal, Québec and Toronto in performing laparoscopic colon and rectal surgery.

METHODS

The prospectively designed case series comprised all patients having laparoscopic colon and rectal surgery. The procedures were carried out by a group of 4 surgeons between April 1991 and November 2001. We noted intraoperative complications, any conversions to open surgery, operating time, postoperative complications and postoperative length of hospital stay.

RESULTS

The group attempted 750 laparoscopic colon and rectal procedures of which 669 were completed laparoscopically. Malignant disease was the indication for surgery in 49.6% of cases. Right hemicolectomy and sigmoid colectomy accounted for 54.5% of procedures performed. Intraoperative complications occurred in 8.3%, with 29.0% of these resulting in conversion to open surgery. The overall rate of conversion to open surgery was 10.8%, most commonly for oncologic concerns. Median operating time was 175 minutes for all procedures. Postoperative complications occurred in 27.5% of procedures completed laparoscopically but were mostly minor wound complications. Pulmonary complications occurred in only 1.0%. The anastomotic leak rate was 2.5%. The early reoperation rate was 2.4%. Postoperative mortality was 2.2%. No port site metastases have yet been detected. The median postoperative length of stay was 5 days.

CONCLUSIONS

The clinical outcomes of laparoscopic colon and rectal surgery in this 10-year experience are consistent with numerous cohort studies and randomized clinical trials. Laparoscopic colon and rectal surgery in the hands of well-trained surgeons can be performed safely with short hospital stay, low analgesic requirements and acceptable complication rates compared with historical controls and other reports in the literature. Evidence from published randomized clinical trials is emerging that under these conditions laparoscopic resection represents the better treatment option for most benign conditions, but concerns regarding its appropriateness for malignant disease are still to be resolved.

Relation of hospital volume to colostomy rates and survival for patients with rectal cancer

BACKGROUND

Postoperative mortality after some types of cancer surgery is inversely related to the number of operations performed at a hospital (i.e., hospital volume). This study assessed the association of hospital volume with colostomy rates and survival for patients with rectal cancer in a large representative cohort identified from the California Cancer Registry.

METHODS

We identified 7257 patients diagnosed from January 1, 1994, through December 31, 1997, with stage I-III rectal cancer who underwent surgical resection. Registry data were linked to hospital discharge abstracts and ZIP-code-level data from the 1990 U.S. Census. Associations of hospital volume with permanent colostomy and 30-day mortality were assessed with the Mantel-Haenszel trend test and logistic regression. Overall survival was examined with the Kaplan-Meier method and a multivariable Cox proportional hazards model. Multivariable analyses adjusted for demographic and clinical variables and patient clustering within hospitals. All tests of statistical significance were two-sided.

RESULTS

In unadjusted analyses across decreasing quartiles of hospital volume, we observed statistically significant increases in colostomy rates (29.5%, 31.8%, 35.2%, and 36.6%; P<.001) and in 30-day postoperative mortality (1.6%, 1.6%, 2.9%, and 4.8%; P<.001) and a decrease in 2-year survival (83.7%, 83.2%, 80.9%, and 76.6%; P<.001). The adjusted risks of permanent colostomy (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.10 to 1.70), 30-day mortality (OR = 2.64, 95% CI = 1.41 to 4.93), and 2-year mortality (hazard ratio = 1.28, 95% CI = 1.15 to 1.44) were greater for patients at hospitals in the lowest volume quartile than for patients at hospitals in the highest volume quartile. Stratification by tumor stage and comorbidity index did not appreciably affect the results. Adjusted colostomy rates varied statistically significantly (P<.001) among individual hospitals independent of volume.

CONCLUSIONS

Rectal cancer patients who underwent surgery at high-volume hospitals were less likely to have a permanent colostomy and had better survival rates than those treated in low-volume hospitals. Identifying processes of care that contribute to these differences may improve patients' outcomes in all hospitals.

[Complicated colon cancer: the experience at an Operative Surgery Unit]

INTRODUCTION

Prognosis of colon cancer is worse if complications are present at the moment of diagnosis. The high mortality rate with surgery in emergency in such cases needs a careful reflection about the best suitable operation to perform.

MATERIALS AND METHODS

107 consecutive patients observed along a 9 year-period for colon-rectal cancer are retrospectively analysed. 27 of them were complicated at the presentation for obstruction (19 patients), colon perforation (6 patients) or rectal hemorrhage (2 patients). In the whole experience 5 patients underwent primary resection of the tumour and direct anastomosis; 5 only a decompressive colostomy; 6 were primarily resected and anastomized under the protection of a cecostomy; 6 other patients underwent a Hartmann procedure; 2 were treated with only an intestinal by-pass; 1 was treated with Miles procedure; 1 with an anterior rectal section and the last one was resected-anastomosed in two steps, after a temporary decompressive colostomy.

RESULTS

Intraoperative mortality was of 11.1% (3 patients) and morbidity 18.5% (5 patients). General 5 years survival was 62.1% among the cases complicated at presentation. The recurrence rate was 8.45%. Both these figures are below a statistical significance (p = 0.57).

CONCLUSIONS

The necessity to treat in emergency the colon cancers reduces the possibility to adopt the best rules of modern programmed oncologic surgery giving up the chemotherapy w/o neoadjuvant radiotherapy with which a preoperative down-staging of the tumour were possible. For these reasons in emergency not only mortality and morbidity are higher than in case of elective surgery, but also metastasization and recurrence are worse because of a more difficult radicality in surgery.