Colostomy and quality of life after spinal cord injury: systematic review

BACKGROUND

Spinal cord injury (SCI) has a significant impact on the quality of life (QoL) of affected patients. The aim of this review was to determine whether colostomy formation improves QoL in patients with SCI.

METHODS

The Cochrane Register, MEDLINE, Embase and CINAHL were searched using medical subject headings. The search was extended to the reference lists of identified studies, ClinicalTrials.gov and the WHO International Clinical Trials Registry. All clinical trials that included spinal injury and QoL, time spent on bowel care, and patient satisfaction with stoma were assessed.

RESULTS

A total of 15 studies were found (including 488 patients with a stoma), of which 13 were retrospective cross-sectional studies and two were case-control studies, one of which was prospective research. Nine of 11 studies focusing on QoL reported that patients' QoL was improved by the stoma, whereas the remaining two studies found no difference. Time spent on bowel care was significantly reduced in all 13 studies that considered this outcome, with patients reducing the average time spent on bowel care from more than 1 h to less than 15 min per day. All 12 studies assessing patient satisfaction with their stoma reported high patient satisfaction.

CONCLUSION

Stoma formation improves QoL, reduces time spent on bowel care, and increases independence. Stoma is an option that could be discussed and offered to patients with spinal cord injury.

Population-based study demonstrating an increase in colorectal cancer in young patients

BACKGROUND

New Zealand has among the highest rates of colorectal cancer in the world and is an unscreened population. The aim of this study was to determine the trends in incidence and tumour location in the New Zealand population before the introduction of national colorectal cancer screening.

METHODS

Data were obtained from the national cancer registry and linked to population data from 1995 to 2012. Incidence rates for colorectal cancer by sex, age (less than 50 years, 50-79 years, 80 years or more) and location (proximal colon, distal colon and rectum) were assessed by linear regression.

RESULTS

Among patients aged under 50 years, the incidence of distal colonic cancer in men increased by 14 per cent per decade (incidence rate ratio (IRR 1·14), 95 per cent c.i. 1·00 to 1·30; P = 0·042); the incidence of rectal cancer in men increased by 18 per cent (IRR 1·18, 1·06 to 1·32; P = 0·002) and that in women by 13 per cent (IRR 1·13, 1·02 to 1·26; P = 0·023). In those aged 50-79 years, there was a reduction in incidence per decade of proximal, distal and rectal cancers in both sexes. In the group aged 80 years and over, proximal cancer incidence per decade increased by 19 per cent in women (IRR 1·19, 1·13 to 1·26; P < 0·001) and by 25 per cent in men (IRR 1·25, 1·18 to 1·32; P < 0·001); among women, the incidence of distal colonic cancer decreased by 8 per cent (IRR 0·92, 0·86 to 0·98); P = 0·012), as did that of rectal cancer (IRR 0·92, 0·86 to 0·97; P = 0·005).

CONCLUSION

The increasing incidence of rectal cancer among younger patients needs to be considered when implementing screening strategies.

The long-term outcome of anti-TNF alpha therapy in perianal Crohn's disease

BACKGROUND

The aim of the present study was to evaluate the long-term outcomes of anti-tumour necrosis factor alpha therapy in perianal Crohn's disease and identify factors predicting response to treatment.

METHODS

Data from hospital clinical records and coding databases were retrospectively reviewed from a tertiary care hospital in Christchurch, New Zealand. The study included 75 adult patients with perianal Crohn's disease commenced on anti-tumour necrosis factor alpha therapy from January 2000 to December 2012. Response to treatment was determined from records relating to clinical evaluation, magnetic resonance imaging follow-up and whether further surgical intervention was required.

RESULTS

73% (55) of all patients and 38 of the 57 (67%) patients with perianal fistulas responded to anti-tumour necrosis factor alpha therapy. Patients with complex fistulas were less likely to improve as compared to patients without fistulising disease. Five of the 57 (13%) patients with perianal fistulas demonstrated complete healing on clinical evaluation; however, magnetic resonance imaging confirmed complete healing in only two. Patients that had taken antibiotics and those that had previously required abscess drainage were less likely to respond to treatment [relative risk (RR) = 0.707 and 0.615, respectively; p = 0.03, p = 0.0001]. Responders were less likely to require follow-up surgery (RR = 0.658, p = 0.014) including ileostomy or proctectomy.

CONCLUSIONS

Although anti-tumour necrosis factor alpha tends to improve symptoms of perianal Crohn's disease, in the long term, it rarely achieves complete healing. Perianal fistulising disease, a history of perianal abscess and antibiotic treatment are predictors of poor response to therapy.

Cohort study of mesenteric panniculitis and its relationship to malignancy

Background

Mesenteric panniculitis (MP) is a rare condition that historically has been associated with the presence of malignancy. Paraneoplastic phenomena in general regress with cure and in most cases with treatment of the cancer. This study was undertaken to determine whether MP regressed with cancer treatment and cure.

Methods

This was a retrospective review of a database of all patients with MP confirmed on CT between 2003 and August 2015 at Christchurch Hospital. Patients were categorized as having malignant or non-malignant disease, and follow-up scans were assessed for remission of MP. Patients with malignancy were further categorized as having malignancy cured or not cured.

Results

A total of 308 patients were identified with possible MP; 135 were excluded as radiological appearances were not typical of MP (43 patients) or there was no follow-up CT (92). Of 173 patients (131 men) included, 75 (43·4 per cent) were diagnosed with malignancy. Follow-up imaging showed that 33 patients (19·1 per cent) had remission of MP, whereas 140 (80·9 per cent) had no remission. There was no difference in the rates of MP remission in the malignancy versus no malignancy groups (P = 1·000), or between groups in which malignancy was cured or not cured (P = 0·572). Nor was there any difference in the rates of MP remission in malignancy cured versus no malignancy groups (P = 0·524).

Conclusion

MP does not behave like a paraneoplastic phenomenon. The association with malignancy is most likely an epiphenomenon of the many CT images acquired for staging of cancer.

Impact of obesity on the cost of major colorectal surgery

BACKGROUND

The incidence of obesity is increasing in New Zealand. The aim of the study was to determine whether obesity impacts on the cost of treating patients undergoing major colorectal surgery.

METHODS

Between 1 February 2008 and 31 July 2009, consecutive patients undergoing major colorectal surgery at Christchurch Hospital, New Zealand, were enrolled in the study. Body mass index (BMI) and waist-to-hip ratios were assessed using standardized techniques. Patients with a high surgical risk were identified using established criteria and all patients were assessed using the Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM). Cost analysis was performed using a structured query language database. Patients were analysed using accepted groupings for BMI, waist circumference and waist-to-hip ratio.

RESULTS

A total of 372 patients were enrolled in the study, of whom 345 were included in the analysis. The incidence of diabetes was significantly higher with increased BMI (P = 0·002), whereas all other co-morbidities, and P-POSSUM values, did not differ between BMI groups. The groups were similar in terms of case mix. Treatment of obese patients (BMI at least 30 kg/m(2)) was significantly more expensive than that of normal weight patients (BMI 20-24·9 kg/m(2)): €10,036 versus €7390 (P = 0·005). Treatment costs for patients with a BMI of 25-29·9 kg/m(2) were next highest (€9048) followed by those for patients whose BMI was less than 20 kg/m(2) (€8884). Patients with a waist circumference above recognized standards for men and women also cost significantly more to treat (€10,063 versus €7836; P = 0·014).

CONCLUSION

Excess body fat was associated with higher costs of major colorectal surgery.

Current practice in preoperative therapy and surgical management of locally advanced rectal cancer: a bi-national survey

AIM

The Australasian colorectal surgeon's current approach to preoperative rectal cancer management was compared with international guidelines.

METHOD

Members of the Colorectal Surgical Society of Australia and New Zealand were surveyed in 2010, on the use of MRI and the management of locally advanced rectal cancer. Surgeons had to decide the appropriate management in five scenarios that were developed from national guidelines.

RESULTS

Of 174 invitations sent, 108 (62.1%) replies were received. Most surgeons (98.1%) had access to MRI. Ninety-three (86.1%) would use MRI routinely for staging. The majority selected a tumour-specific mesorectal resection for upper rectal cancer (58.2%) and a total mesorectal excision for distal cancer (100%). Almost all restorative operations included a covering ileostomy. One third of surgeons recommended that patients with a favourable cT3 mid-rectal tumour (N0, clear circumferential resection margins) should not have preoperative therapy and should proceed directly to surgery. When high-risk features, such as threatened resection margins or cN1 stage, were present, 5% and 15% of surgeons, respectively, would continue to treat by standard resection without preoperative therapy.

CONCLUSION

Evidence-based international guidelines for the management of rectal cancer have changed little in the last 10 years. Despite this, there is a clear gap between these and clinical practice. The main variance relates to the role of radiotherapy in locally advanced rectal cancer. Despite considerable evidence that radiotherapy reduces local recurrence for all stages of rectal cancer, current practice in Australasia is for its selective use.

Ileal disease is associated with surgery for perianal disease in a population-based Crohn's disease cohort

BACKGROUND

The aim of this study was describe the frequency and characteristics of perianal surgical intervention (PSI) for Crohn's disease in a population-based cohort of patients with inflammatory bowel disease (IBD).

METHODS

A total of 1421 patients with IBD were recruited, representing approximately 91 per cent of people with IBD in Canterbury, New Zealand. The clinical notes were screened to confirm the diagnosis and extract clinical data, including details of PSIs.

RESULTS

Some 649 patients with Crohn's disease were included in the analysis, of whom 119 (18.3 per cent) had at least one PSI. Of these, 61 (51.3 per cent) required further procedures. Operations for perianal abscess and fistula accounted for 72.4 per cent of interventions. PSI rates did not differ between the sexes (P = 0.218). Age less than 17 years (adjusted odds ratio (OR) 1.89 (95 per cent confidence interval 1.08 to 3.28)) and ileal disease (OR 1.76 (1.06 to 2.92)) were identified as predictors of PSI. As disease duration increased, so did the proportion of patients with complicated intestinal disease among those who had undergone PSI. The median time to first PSI from diagnosis of Crohn's disease was 28 (interquartile range 7-82) months. Sex, age at diagnosis and disease location did not influence the time to first PSI.

CONCLUSION

PSIs are frequent in patients with Crohn's disease, particularly those with ileal disease and those diagnosed at a young age.

Why barium enemas fail to identify colorectal cancers

BACKGROUND

The aim of the present study was to determine the cause and clinicopathological factors associated with the failure of barium enemas to detect colorectal cancers.

METHODS

A histopathological database was used to identify all patients with a diagnosis of colorectal cancer between 1991 and 1995. These records were matched with the records from patients who underwent barium enema examinations between 1990 and 1995. Those patients who had a colorectal cancer histologically diagnosed within 24 months of a barium enema in which no carcinoma was seen, were identified. Where possible the radiology was reviewed. Failure to identify a carcinoma was then attributed to either simple failure, technical, interpretive or perceptive difficulties.

RESULTS

There were 967 patients with colorectal cancers treated in Christchurch Hospital during the study period 1991-1995. Matching of these patient details with all barium enema records revealed 313 patients who had barium enemas and histologically proven colorectal cancer. There were 21 (6.7%) patients in whom a carcinoma was missed. Of these, 18 had a barium enema within 8 months of surgery, and three were performed outside this timespan (15, 18 and 28 months, respectively). On review, 11 carcinomas could not be identified (nine due to technical error: poor coating (n = 1), overlapping loops (n = 3), single-contrast enema (n = 4), faecal residue (n = 1)); and seven could be seen on review of the films (two interpretation errors, one technical and perceptive error, and four perceptive errors). In three cases films could not be found for review. In 16 of the 21 missed lesions the patient had a double-contrast barium enema (DCBE) while five patients had single-contrast barium enema (SCBE). The site and stage of missed tumours is presented.

CONCLUSIONS

The most common reason for missed tumours was technical. The percentage of missed tumours in each region of the bowel correlates with the known incidence of tumours in each region and with a normal Dukes stage distribution, except in the caecum where the number of missed lesions was higher than expected.

Clarification of the process of separation of the cloaca into rectum and urogenital sinus in the rat embryo

BACKGROUND/PURPOSE

The normal process of division of the cloaca into a rectum and urogenital tract is still not fully understood. The main controversies relate to how the urorectal septum (URS) divides the cloaca and whether the URS fuses with the cloacal membrane. This study used a 3-dimensional reconstruction technique, combined with histologic correlation, to observe the developmental and septational processes of the cloaca of the normal rat embryo from gestational days 11 to 16.

METHODS

Normal rat embryos from gestational days 11 to 16 were sectioned serially both transversely and sagittally and stained with H&E. 3-dimensional reconstructions were performed on embryos younger than day 13.5. The relevant structures were examined in a temporo-spatial sequence.

RESULTS

The tailgut started to regress by apoptosis on day 12 in a cranio-caudal direction. The URS, first evident in day-12.5 embryos, extended and fused with the cloacal membrane on day 15 of gestation, completing the separation of the cloaca into rectum and bladder. Regression of the tailgut and ventral protrusion of the urogenital sinus markedly changed the configuration of the cloaca. The cloacal membrane did not break down until after it had fused with the URS.

CONCLUSIONS

These findings clarify the relative contributions made by active septation of the cloaca by the URS and configurational changes of the cloaca to produce a rectum and bladder. The URS fuses with the cloacal membrane before the anal and urogenital membranes break down.

Does the urorectal septum fuse with the cloacal membrane?

PURPOSE

Traditional theories of cloacal embryogenesis assume that the urorectal septum fuses with the cloacal membrane before the anal membrane disintegrates. However, recent observations in humans and other species raise doubt about this assumption. We determined whether urorectal septum fusion occurs in rats.

MATERIALS AND METHODS

Rat embryos were harvested at specific times between days 11 and 16 of gestation. We evaluated the morphology, growth and relationship of the urorectal septum to the cloacal membrane on serial histological sections.

RESULTS

The urorectal septum consistently fused with the cloacal membrane on day 15 of gestation before the cloacal membrane began to disintegrate.

CONCLUSIONS

In rats the urorectal septum fuses with the cloacal membrane, after which the urogenital membrane and anal membrane disintegrate by a process of apoptosis.

Technique training: endoscopic percutaneous tracheostomy

Percutaneous tracheostomy is being used increasingly in the intensive care unit and endoscopic control of this procedure affords an improved level of safety. Training in such new minimal access techniques can be a significant risk factor in patient outcome. Surgical simulation provides training which minimizes this risk. We present a method of training in percutaneous endoscopic tracheostomy using a simulation model based on animal tissue. Our experience with this model is reported.