Effect of obesity on post-operative outcomes following colorectal cancer surgery

BACKGROUND

Colorectal cancer (CRC) resection is currently being undertaken in an increasing number of obese patients. Existing studies have yet to reach a consensus as to whether obesity affects post-operative outcomes following CRC surgery.

AIM

To evaluate the post-operative outcomes of obese patients following CRC resection, as well as to determine the post-operative outcomes of obese patients in the subgroup undergoing laparoscopic surgery.

METHODS

Six-hundred and fifteen CRC patients who underwent surgery at the Prince Charles Hospital between January 2010 and December 2020 were categorized into two groups based on body mass index (BMI): Obese [BMI ≥ 30, n = 182 (29.6%)] and non-obese [BMI < 30, n = 433 (70.4%)]. Demographics, comorbidities, surgical features, and post-operative outcomes were compared between both groups. Post-operative outcomes were also compared between both groups in the subgroup of patients undergoing laparoscopic surgery [n = 472: BMI ≥ 30, n = 136 (28.8%); BMI < 30, n = 336 (71.2%)].

RESULTS

Obese patients had a higher burden of cardiac (73.1% vs 56.8%; P < 0.001) and respiratory comorbidities (37.4% vs 26.8%; P = 0.01). Obese patients were also more likely to undergo conversion to an open procedure (12.8% vs 5.1%; P = 0.002), but did not experience more post-operative complications (51.6% vs 44.1%; P = 0.06) or high-grade complications (19.2% vs 14.1%; P = 0.11). In the laparoscopic subgroup, however, obesity was associated with a higher prevalence of post-operative complications (47.8% vs 39.3%; P = 0.05) but not high-grade complications (17.6% vs 11.0%; P = 0.07).

CONCLUSION

Surgical resection of CRC in obese individuals is safe. A higher prevalence of post-operative complications in obese patients appears to only be in the context of laparoscopic surgery.

Can you hear me? Analysis of a Queensland patient-initiated escalation process and the importance of communication in surgical care

BACKGROUND

Ryan's Rule is a three-step escalation process established by Queensland Health whereby patients, their families and carers can escalate concerns if a patient's health is worsening or not improving as expected. This study analysed the incidence, causes and outcomes of Ryan's Rule cases involving patients admitted under various surgical specialties across Queensland.

METHODS

A retrospective analysis was undertaken of cases wherein Ryan's Rule was invoked by surgical patients between 2016 and 2021. The analysis focused on rationale for invoking Ryan's Rule, clinical actions undertaken, outcomes and patient feedback.

RESULTS

The study analysed 364 activations of Ryan's Rule among surgical patients admitted across ten Queensland Health hospitals. The common causes for invoking Ryan's Rule were concern or disagreement regarding the management plan (39%), poor understanding of the care plan (32%) and feeling that concerns were not being heard (35%). Less than 1 % of cases (0.8%) met early warning criteria for deterioration, and only 0.5% required admission to ICU. The majority of Ryan's Rule cases (92%) were resolved through discussion between the treating surgical team, the patient and their representatives. In 74% of cases, the management plan did not change following the Ryan's Rule review.

CONCLUSION

Communication is the overwhelming theme throughout the Ryan's Rule cases invoked by surgical patients. The majority of Ryan's Rules cases were initiated by issues in communication and understanding between clinicians and patients. The vast majority of cases were resolved by surgical teams establishing and maintaining clear communication with patients, their families and carers.

Should we resect colorectal cancer in patients over the age of 85?

BACKGROUND

The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population.

AIM

To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85.

METHODS

Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient’s over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed.

RESULTS

The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups.

CONCLUSION

No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.

The impact of comorbidities on post-operative complications following colorectal cancer surgery

Background

Colorectal cancer surgery is complex and can result in severe post-operative complications. Optimisation of surgical outcomes requires a thorough understanding of the background complexity and comorbid status of patients.

Aim

The aim of this study is to determine whether certain pre-existing comorbidities are associated with high grade post-operative complications following colorectal cancer surgery. The study also aims to define the prevalence of demographic, comorbid and surgical features in a population undergoing colorectal cancer resection.

Method

A colorectal cancer database at The Prince Charles Hospital was established to capture detailed information on patient background, comorbidities and clinicopathological features. A single-centre retrospective study was undertaken to assess the effect of comorbidities on post-operative outcomes following colorectal cancer resection. Five hundred and thirty-three patients were reviewed between 2010–2018 to assess if specific comorbidities were associated with higher grade post-operative complications. A Clavien-Dindo grade of three or higher was defined as a high grade complication.

Results

Fifty-eight percent of all patients had an ASA grade of ASA III or above. The average BMI of patients undergoing resection was 28 ± 6.0. Sixteen percent of all patients experienced a high grade complications. Patients with high grade complications had a higher mean average age compared to patients with low grade or no post-operative complications (74 years vs 70 years, p = 0.01). Univariate analysis revealed patients with atrial fibrillation, COPD, ischaemic heart disease and heart failure had an increased risk of high grade complications. Multivariate analysis revealed pre-existing atrial fibrillation (OR 2.70, 95% CI 1.53–4.89, p <0.01) and COPD (OR 2.02 1.07–3.80, p = 0.029) were independently associated with an increased risk of high grade complications.

Conclusion

Pre-existing atrial fibrillation and COPD are independent risk factors for high grade complications. Targeted perioperative management is necessary to optimise outcomes.

Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature

BACKGROUND

Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.

CASE SUMMARY

A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann’s procedure for treatment of his colorectal cancer.

CONCLUSION

This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.

Can trained lay providers perform HIV testing services? A review of national HIV testing policies

BACKGROUND

Only an estimated 54% of people living with HIV are aware of their status. Despite progress scaling up HIV testing services (HTS), a testing gap remains. Delivery of HTS by lay providers may help close this testing gap, while also increasing uptake and acceptability of HIV testing among key populations and other priority groups.

METHODS

50 National HIV testing policies were collated from WHO country intelligence databases, contacts and testing program websites. Data regarding lay provider use for HTS was extracted and collated. Our search had no geographical or language restrictions. This data was then compared with reported data from the Global AIDS Response Progress Reporting (GARPR) from July 2015.

RESULTS

Forty-two percent of countries permit lay providers to perform HIV testing and 56% permit lay providers to administer pre-and post-test counseling. Comparative analysis with GARPR found that less than half (46%) of reported data from countries were consistent with their corresponding national HIV testing policy.

CONCLUSIONS

Given the low uptake of lay provider use globally and their proven use in increasing HIV testing, countries should consider revising policies to support lay provider testing using rapid diagnostic tests.

Urinoma secondary to surgical spinal fusion: radiologic diagnosis and treatment

We have presented a case of urinoma secondary to ureteral injury during spinal fusion via retroperitoneal approach demonstrated by CT. The presumed diagnosis of urinoma was confirmed and treated by interventional radiologic techniques.

Effects of suspension hypokinesia/hypodynamia on rat skeletal muscle

We studied the effects of suspension hypokinesia/hypodynamia (H/H) on properties of soleus and plantaris muscles of rats. Our objective was to compare the effects of this model to those of disuse atrophy. After 12 d of H/H, there were significant decreases in soleus and plantaris muscle wet weight and citrate synthase activity. Soleus muscle was affected to a greater extent than plantaris muscle. There was a significant decrease in non-collagen protein content of H/H soleus muscle. Triceps brachii muscles did not display significant changes in any parameters measured, suggesting that observed changes were not due to systemic factors. There was no significant change in the water content of H/H soleus or plantaris muscles. Suspension H/H causes muscle changes different from those secondary to limb immobilization, in which soleus and plantaris muscles are equally affected.