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There has been a great push from surgeons (good quality surgery) and pathologist (careful examination) to maximise the lymph node yield from surgical resections. This large Swedish study with 3536 patients were divided into three groups based on the year in which they were operated (period 1, 1996–1999; period 2, 2000–2004; and period 3, 2005–2009). The mean number of lymph nodes examined increased significantly during the overall study period (seven in period 1, 11 in period 2 and 18 in period 3; P < 0.001). However, the increase in lymph node yield did not result in change of nodal stage (N1/N2) for all 3 cohorts. Despite improving lymph node yield does not appear to translate to a change in stage of disease.
Chronic anal fissures are difficult to manage and a balance has to be struck between failure rates from non surgical options versus incontinence from definitive sphincterotomy. In this American study of over 200 patients, the authors conducted a bottom-up treatment algorithm of GTN, Botox and sphincterotomy for fissures but allowed patients to choose any of the 3 options upfront should they choose to. Those patients who chose a bottom-up approach had failure rates of 30% from GTN, 10% from Botox and 4% from sphincterotomy. Failure rates did not seem to differ in those who chose BTX or definitive surgery upfront compared with those who chose a bottom-up approach. Although continence was preserved in those who had sphincterotomies, one quarter of patients had significant morbidity from prolonged wound healing of up to 18 weeks.
It would appear that the genetics for bowel cancer are more complex then previously thought. In this study 1443 colorectal cancers in two US nationwide prospective cohort studies were studied. Frequencies of molecular features were examined along bowel subsites (rectum, rectosigmoid junction, sigmoid, descending colon, splenic flexure, transverse colon, hepatic flexure, ascending colon and caecum). The frequencies of CIMP-high, MSI-high and BRAF mutations gradually increased from the rectum (<2.3%) to ascending colon (36–40%), followed by falls in the caecum (12–22%). Caecal cancers exhibited the highest frequency of KRAS mutations (52% vs 27–35% in other sites; p<0.0001).
A Meta-analysis of the Effectiveness of the Opioid Receptor Antagonist Alvimopan in Reducing Hospital Length of Stay and Time to GI Recovery in Patients Enrolled in a Standardized Accelerated Recovery Program After Abdominal Surgery
One of the major drawbacks following colorectal surgery is that of postoperative ileus. Despite introductions of enhanced recovery packages, a significant proportion of patients are not fit for discharge because of failure of gut function. In this systematic review, the authors pooled analysis from three RCT trials with a total of 1388 patients who underwent open abdominal surgery; 685 (49%) patients received alvimopan. On meta-analysis, alvimopan reduced time to the hospital discharge order (HR 1.37 (1.21, 1.62), p < 0.0001), and accelerated the recovery of gut function (HR 1.42 (1.25, 1.62), p < 0.001). Alvimopan 12 mg can further reduce time to gut recovery and accelerate hospital discharge in patients undergoing abdominal surgery within an accelerated recovery program. Investigation into the effect of alvimopan following laparoscopic surgery and additional cost-benefit analyses are required to further define the role of this intervention.
The aim of this study was to compare the effects at high tie and low tie transections on colonic length after oncological sigmoidectomy, theoretical feasibility of colorectal anastomosis at the sacral promontory and a straight will J pouch colo-anal anastomosis following TME. The study was undertaken in the surgical anatomy research unit using the 30 non- embalmed cadavers. Distance from proximal colon to lower edge of pubis symphysis was serially recorded. The successive mean gains in length in high-tie vs low-tie vascular transections were 2.9±1.2 cm vs 3.1 ± 1.8 cm (p = 0.83) after IMA division, 8.1 ± 3.1 cm vs 2.5 ± 1.2 cm (p = 0.0016) following IMV division at the lower part of the pancreas, and 8.1 ± 3.8 cm vs 3.3 ± 1.7 cm (p = 0.0016)after sigmoidectomy. Mean cumulative gain in length was significantly higher in high-tie vs low-tie vascular transections (19.1 ± 3.8 vs 8.8 ± 2.9 cm, p = 0.00089). After secondary left colic artery division, gain in length was similar to the high-tie group (17 ± 3.1 vs 19.1 ± 3.8 cm) (p = 0.089). Colorectal anastomosis at the promontory and straight and J-pouch coloanal anastomosis feasibility rates were 100% in the high-tie group, 87%, 53%, and 33% in the low-tie group, but 100%, 100%, and 87% after secondary left colic artery division.
Diseases of the Colon & Rectum 2012;55:515–521
The authors aimed to assess the association between the number of preoperative immunosuppressive therapies and unplanned Hospital readmission after surgery in patients with Crohn's disease. Consecutive patients with Crohn's requiring abdominal surgery were identified from a prospective data base with immunosuppressive therapies within 3 months before surgery categorised into steroids, immunomodulators and biologics. Un-planned readmission within 30 days of discharge was assessed. 338 patients were identified of whom 63 (19%) were not treated with any immunosuppressive medication preoperatively. 28 patients had unplanned readmission with a similar incidence on patients treated with steroids (11%), immunomodulators (9%) and biologics (12%).Incidence of unplanned readmission was 3%, 7%, 11%, and 16% in patients treated with 0, 1, 2, or 3 preoperative medication classes (trend analysis p = 0.02.
Diseases of the Colon & Rectum 2012;55:563–568
The authors aimed to compare the outcome of haemorrhoidal ligation with and without the use of a Doppler transducer. A single blinded clinical trial randomised 82 patients with grade 2 and 3 haemorrhoids to either Howell with or without Doppler transducer. After 6 weeks and 6 months in both groups significant improvement was observed with regard to blood loss, pain, prolapse problems with defecation (P < 0.05). Improvement of symptoms between both groups to differ significantly except prolapse which improved more in the non-Doppler group (P = 0.047). After 6 months 31% of patients in the non-Doppler group and 21% in the Doppler group were completely complaint free.
Annals of Surgery 2012;255:840–845
The authors aimed to evaluate long-term clinical and manometric results of fistulotomy and sphincter Reconstruction and treatment of complex fistulas in ano. 70 patients diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter Reconstruction with preoperative physical examination, anorectalmanometry and anal endoultrasound undertaken. Followup was every 6 months for the first and second years after treatment then 2 years thereafter. Continence was assessed according to the Wexner score. Medium to high transsphincteric fistulas were identified and 64 patients. 22 (32%) patients reported faecal incontinence preoperatively of which 15 improved post operatively. 8 (16.6%) reported post-operative incontinence with 6 (8.5%) suffering recurrent incontinence.
Annals of Surgery 2012;255:935–939
This study evaluates the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery. This was an observational, prospectively designed cohort study evaluating patients undergoing elective left-sided colon or rectal resections between October 1, 2005, to December 31, 2009. Among 3449 patients the composite adverse event rate was 5.5%. Provocative leak testing increased (from 56% to 76%) and overall rates of composite adverse events decreased from 7.0% to 4.6%, p=0.01 over the same time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of composite adverse events (odds ratio, 0.23; 95% CI, 0.05-0.99). Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of adverse events.
This study investigates the incidence and risk factors for small-bowel obstruction (SBO) after certain surgical procedures. The Inpatient Register held by the Swedish National Board of Health and Welfare was used was analysed. Hospital discharge diagnoses and registered performed surgical procedures identified data for cholecystectomy, hysterectomy, salpingo-oophorectomy, bowel resection, anterior resection, abdominoperineal resection, rectopexy, appendectomy, and bariatric surgery performed between January 1, 2002 to December 31, 2004. Demographic characteristics, comorbidity, previous abdominal surgery, and death were collected and compared to episodes of hospital stay and surgery for SBO within 5 years after the index surgery. A total of 108,141 patients were included and the incidence of SBO ranged from 0.4% to 13.9%. Multivariate analysis revealed age, previous surgery, comorbidity, and surgical technique to be risk factors for SBO. Laparoscopy exceeded other risk factors in reduction of the risk of SBO for most of the surgical procedures. They conclude that open surgery increases the risk of SBO at least 4 times compared with laparoscopy for most of the abdominal surgical procedures studied. Other factors such as age, previous abdominal surgery, and comorbidity are also of importance.
This study identifies factors that influence the total and negative lymph node counts in colorectal cancer resection specimens independent of pathologists and surgeons. They used multivariate negative binomial regression to identify factors that influence total and negative lymph node counts. They found that specimen length, tumor size, ascending colon location, T3N0M0 stage, and year of diagnosis were positively associated with the negative node count (P<.002). Among node-negative cases, specimen length, tumor size, and ascending colon location remained significantly associated with the node count (all P<.002). They conclude that specimen length, tumor size, tumor location, TNM stage, and year of diagnosis are operator-independent predictors of the lymph node count.
The authors aimed to assess a new procedure for full thickness rectal prolapse. Eighteen women with full thickness prolapse were assessed with validated quality of life questionnaires and continence scores, colonoscopy and manometry. Ten had newly diagnosed prolapse and eight recurrent prolapse. The Altemeier procedure was combined with a levatorplasty and completed with a manual or stapled colo-anal anastomosis. At 30 months there were no recurrences. No mortality or post operative complications were recorded. All patients reported improved quality of life and faecal incontinence scores.
The authors aimed to assess the effects of a biological material to support an overlapping sphincter repair to the entire circumference of the external sphincter due to radiation or trauma. A tunnel was created under the damaged external anal sphincter and encircle the anal canal. A biological graft is then inserted through the tunnel and sutured to the muscle after being pulled firmly to close the patulous anus. An overlapping repair is then carried out. 13 patients underwent this procedure with the average age of 68.6 years. The mean followup was 16.3 months. The average length of stay was one day with no complications reported. Post operatively incontinence severity scores and quality-of-life scales showed improvement and incontinence episodes were markedly decreased to once per week.
For a select group of patients proctectomy with intersphincteric resection colorectal cancer may be a viable alternative to APR with good oncological outcomes whilst preserving sphincter function. This systematic review evaluated current evidence regarding oncological outcomes morbidity mortality and functional outcomes after intersphincteric resection colorectal cancer. This systematic review the literature was undertaken evaluating oncological outcomes morbidity and mortality colorectal cancer. 84 studies were identified with 14 studies involving 1289 patients being included. Mean age is 59.5 years and 67% were Male. R 0 resection was achieved 97% was operative mortality rate of 0.8% and morbidity rate of 25.8%. Eating followup was 56 months with mean local recurrence of 6.7% five-year overall and disease-free survival rate of 86.3 and 78.6% respectively.
The authors aimed to assess concerns regarding the safety of non-steroidal anti-inflammatory drugs in terms of an anastomotic healing. Retrospective analysis was performed over a two-year period on patients undergoing primary colorectal anastomosis to teaching hospitals. Exact use of non-steroidals was recorded with rate of an anastomotic leakage been compared between groups and corrected to known risk factors in both unit area to multivariate analysis. 795 patients were divided into 4 groups according to NSAID use, no NSAID, use of non-selective NSAID's and selective cyclo-oxygenase inhibitors. Overall leak rate was 9.9% other known risk factors such as smoking and use of steroids were not significantly associated with leaks. Staple anastomosis was identified independent predictor of leakage in multivariate analysis. Patient on NSAID's had higher anastomotic leak rates.
The authors speculated increased risks related to surgery may reflect nutritional status of patient's with an 18 to identify the relative importance of nutritional risk screening along with established medical anaesthetic and surgical predictors of post-operative morbidity and mortality. This was prospectively undertaken on patients scheduled for elective abdominal operations. Data was collected on nutritional variables age sex, type and extent of operation underlying disease ASA and comorbidities. Relative complication rates were calculated with multiple logistical regression and tumours or proportional of the models. 653 patient's reenrolled of whom 20.2% sustained one or more post-operative complications. The frequency of this event increased with a low fluid intake before hospital admission. No other individual or composite nutritional variable provided comparable or better risk prediction. ASA, male sex, underlying disease and extent of surgical procedure were also associated with post-operative complications.
The authors sought to evaluate several markers in the apoptotic pathway and expression of Cox-2 and VEGF to determine and predict their response to neoadjuvant therapy. 152 patients with advanced rectal carcinoma were treated and underwent resection. Paraffin embedded sections obtained before and after resection were immunohistochemically stained for Cox-2, VEGF, p53, p21, p27, Bax, BCL-2 and apoptosis protease-activating factor 1 (APAF-1). Stains were correlated with tumour regression, grade and pathological response. Pathological response was seen in 24.5% and only APAF-1 expression was found to be significantly associated with tumour regression grade ( < 0.001), complete pathological response ( < 0.031) and T-downstaging ( < 0.004). Multivariate analysis showed APAF-1 expression to be independently associated with tumour regression. Overexpression of Cox-2 and VEGF in pre treatment biopsied was associated with less tumour regression and less likelihood of T staging.
Cytoreductive surgery and intraperitoneal chemotherapy have been advocated as standard treatment for appendiceal neoplasms with isolated peritoneal metastases. However, the optimal method for chemotherapy administration has not been established. This study aimed to describe the associated time to progression and morbidity of those with appendicael neoplasms and peritoneal dissemination. It was undertaken retrospectively over a 15 year period. 50 patients were identified. All underwent intrapperitoneal catheter placement after complete cytoreductive surgery. 34% of patients experienced complications;12% major complications. No 30 day mortality was recorded. 5 year recurrence free interval was 43%. Median overall survival was 9.8 years.
The authors sought to identify differences in postoperative complications following abdominal vs transperineal approaches to rectal prolapse. The study was retrospective over a 4 year period. Surgical outcome was compared in standard abdominal approaches compared with standard transperineal approaches. Primary outcome measures were morbidity outcome and 30-day mortality. 1485 patients underwent rectal prolapse surgery in that time, 706 abdominal and 779 transperineal. Those treated with abdominal approaches had increased risks of infectious and overall complications. Multivariate analysis showed ASA 4 and abdominal surgery to be risk factors for overall complications with alumin>2.5 being protective. Risk factors for infectious complications were ASA, BMI>25 and an abdominal approach.
The authors evaluated the incidence of synchronous metastatic disease in FDG-PET/CT and contrast enhanced multi row detector computed CT (ceMDCT) in MRI stratified high and low risk rectal cancer. The aim was to determine incidence of synchronous metastatic disease according to MRI risk features. 236 patients were recruited into the study with all being stratified into high and low risk groups. Confirmed metastases were those identified on FDG-PET/CT and ceMDCT. Incidence of metastases was significantly higher in the MRI high risk group (20.7%) vs the low risk group (4.2%).
The authors postulated that adjuvant chemotherapy adds minimal oncological benefit for patients undergoing TME who are node negative after neoadjuvant chemo-radiotherapy. A prospectively maintained database identified patients over an eight year period. Patient, tumour, treatment characteristics, and oncologic outcomes were compared for patients who completed intended adjuvant chemotherapy (group chemo) or did not receive any chemotherapy (group no-chemo). The no-chemo group had greater complete pathologic response ( = 14, 24.1%). With prolonged follow-up, local recurrence ( = 1), disease-free survival ( = 0.41), and overall survival ( = 0.52) were similar. Benefits of adjuvant chemotherapy were especially questionable for patients with complete pathologic response (chemo vs. no-chemo, local recurrence at 5 years: 0 vs. 2.9%, > 0.99), disease-free (79.1% vs. 88%, = 0.51), and overall survival (90.9% vs. 95.2%, = 0.41). = 34, 48.6% vs.
The authors aimed to examine modifiable risk factors for anastomotic leaks in patients undergoing anterior resection. 233 patients undergoing a low anterior resection for benign and malignant disease were identified over a 10 year period in a single operative centre from a prospective database. Seventeen variables were assessed for a relationship with anastomotic leak. 90 % of cases were performed for rectal cancer. The overall leak rate was 14%. This was associated with a higher 30day mortality (6%vs1%) and a longer hospital stay ( 23 vs 10 days). Multivariate analysis indicated smokers (OR 3.68 95%CI 1.38-9.82, p=0.009) and patients with evidence of metastatic disease (OR 3.43, 95% CI 1.29-0.13) were at increased risk of anastomotic leak.
The authors undertook a double blind placebo crossover trial of 14 female patients with evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity. Sacral nerve stimulation was performed in the standard 2 stage technique. Patients were randomised during a temporary stimulation period to on-off/off-on for a 2 week period. 13 patients completed the trial. There was a significant increase in successful bowel movements and wexner constipation scores improved. No significant changes in disease specific or generic QOL measures were recorded.
Pelvic sepsis after IPAA predisposes to pouch failure but there are limited data on long-term pouch function for patients with pelvic sepsis. In this single institution study of more than 3000 patients, the authors noted that pelvic sepsis was associated with greater pouch failure (19.5% vs 4%, p < 0.001). For patients with a retained pouch and were amenable to follow-up, patients who had pelvic sepsis had poorer incontinence scores and poorer quality of life (Cleveland Global Quality of Life scores) compared to those without sepsis.
The authors conducted a meta‐analysis of high‐quality evidence comparing preoperative SEMS with emergency surgery for acute malignant left‐sided colonic obstruction. Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in‐hospital mortality, anastomotic leak, 30‐day reoperation and surgical‐site infection rates.
Is there any evidence that patients with Crohn’s disease should have laparoscopic resections? The authors performed a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database and identified 1917 ileocolic resections, of which 644 (34%) were performed laparoscopically. At baseline, the open group was significantly older, had more comorbidities, higher American Society of Anesthesiology (ASA) classes, and more intra-operative transfusions (all variables, P < 0.05). On multivariate analysis, laparoscopic ileocolic resections were associated with a decrease in major (OR = 0.629, 95% CI: 0.430–0.905, P = 0.014) and minor (OR = 0.576, 95% CI: 0.405–0.804, P = 0.002) complications compared with open resections. Laparoscopy was associated with a significant reduction in adjusted length of stay compared with the open approach (−1.08 ± 0.29 days, P = 0.0002).
Parastomal hernias are a frequent complication of enterostomies that require surgical treatment in approximately half of patients. This systematic review aimed to evaluate and compare the safety and effectiveness of the surgical techniques available for parastomal hernia repair. Thirty studies were included with the majority retrospective. Suture repair resulted in a significantly increased recurrence rate when compared with mesh repair (odds ratio [OR] 8.9, 95% confidence interval [CI] 5.2–15.1; P < 0.0001). Recurrence rates for mesh repair ranged from 6.9% to 17% and did not differ significantly. In the laparoscopic repair group, the Sugarbaker technique had less recurrences than the keyhole technique (OR 2.3, 95% CI 1.2–4.6; P = 0.016). Morbidity did not differ between techniques. The overall rate of mesh infections was low (3%, 95% CI 2) and comparable for each type of mesh repair.
The authors aimed to evaluate the ability of FDG-PET to predict the long term prognosis based on the response to neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer. Prospectivley 127 patients were enrolled obver a 6 year period. FDG_PET parametes were assessed by at least 2 board certified nuclear medical physicians and included mean standard uptake value, standard uptake value total lesion glycolysis, and visual response score. The main outcome measures were time to recurrence and disease-specific survival. 82 (65%) were male with mean age 60 years. 110 patients had stage II/III disease and 7 had stage IV disease. Median follow up was 77 months. At 5 years 74% had not had recurrence. 5 year disease specific survival was 89%. No FDG-PET partameter was associated with disease specific survival.
Management approaches for colonic volvulus are infrequently described in the literature in the US and many studies only report operative cases. The aim of this study was to define the demographics, diagnostic and treatment approaches and outcomes for patients with this disorder in the USA. A retrospective review was performed in a 7 hospital health system. All patients with colonic volvulus based on ICD9 codes were included. Primary outcome measures were recurrence, complications and mortality. 103 cases of volvulus were identified in 92 patients, Sigmoid volvulus was more common in men, patients with neurological diagnoses and residents in nursing homes 17 % were diagnosed on xray, 27% on contrast studym 35% on CT and 17% at laparotomy. All patient sith caecal volvulus were treated surgically. 79% of sigmoid volvulus were treated operatively. Resection and anastomosis were chosen in most cases (78%), End ostomy in 10% and reduction and pexy in 7%. Complication rates were higher in sigmoid volvulus
The aim of this study was to report postoperative morbidity after low anterior resection and coloanal anastomosis for rectal cancer and identify risk factors for complications. 483 consecutive low anterior resections were analysed that had been carried out at a single centre between 1996 and 2005. Complications up to 3 months post LAR and 3 months after the closure of ileostomy were graded according to the Dindo classification. 164 (33.9%) suffered at least one complication that lead to death in 2 patients. Grade III/IV complications occurred in 69 (14.2%). Multivariate analysis showed male sex (P = 0.0216) and postoperative transfusion (P = 0.0025) to be associated with complications. Circumferential tumour localization was predictive of surgical complications (P = 0.0015). The only factor associated with a risk of leakage was transfusion (P = 0.0216).
The authors of this paper aimed to summarise the literature for the use of fistula plugs in Crohn’s and non Crohn’s fistula in ano. PubMed, MEDLINE, Embase and Cochrane databases were searched between 1995 and 2011. Studies were included if results could be differentiated between Crohn’s and non-Crohn’s patients. Studies with mean follow up less than 3 months were excluded . Overall fistula closure rates and length of follow up were measured. 76 articles or abstracts were identified with 20 studies finally included. Sample sizes ranged from 4-60. 530 patients were included overall (488 non-Crohn’s and 42 Crohn’s) The proportion of patients achieving fistula closure varied between studies for non-Crohn's, 0.2 (95% CI 0.04–0.48) to 0.86 (95% CI 0.64–0.97). The pooled proportion achieving fistula closure in patients with non-Crohn's fistula was 0.54 (95% CI 0.50–0.59). The proportion achieving closure in Crohn's disease was similar (0.55, 95% CI 0.39–0.70).