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System-based factors influencing intraoperative decision-making in rectal cancer by surgeons. An international assessment
Aim: Sound surgical judgement is the goal of training and experience, however system-based factors may also colour selection of options by a surgeon. We analyzed potential organizational characteristics, which might influence rectal cancer decision-making by an experienced surgeon.Method: 173 international centers treating rectal cancer were invited to participate in a survey assessment of key treatment options for patients undergoing curative rectal cancer surgery. The key organizational characteristics were analyzed by multivariate methods for association with intraoperative surgical decision-making.Results: The response rate was 71% (123 centers). Sphincter saving surgery was more likely to be performed at university hospitals (OR = 3,63, p = 0,01) and by high caseload surgeons (OR = 2,77 p = 0,05). A diverting stoma was performed more frequently in departments with clinical audits (OR = 3,06, p = 0,02), and a diverting stoma with coloanal anastomosis was more likely in European centers (OR = 4,14, p = 0,004). One stage surgery was less likely where there was assessment by a multidisciplinary team (OR = 0,24, p = 0,02). Multivariate analysis showed that university hospital, clinical audit, European centre, multidisciplinary team, and high caseload significantly impacted on surgical decision-making.Conclusion: Treatment variance of rectal cancer surgeons appears to be significantly influenced by organizational characteristics and complex team-based decision making. System based factors may need to be considered as a source of outcome variation which may impact on quality metrics.© 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland
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New treatment for faecal incontinence using zinc-aluminium ointment: a double-blind randomized trial (Col. Dis. Volume 14, 2012).
We read with interest the article by Pinedo et al on the use of zinc-aluminum ointment for the treatment of faecal incontinence.1 While the authors of the study provide evidence for the potential efficacy of topical aluminum based therapies, they fail to explain the rationale for including zinc in this preparation. This seems somewhat surprising given the emphasis placed throughout the text on this constituent of the ointment.© 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland
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Secondary diabetes associated with 5-Fluorouracil-based chemotherapy regimens in non-diabetic patients with colorectal cancer: results from a single centre cohort study
Aim: The aim of the study was to analyze the prevalence and characteristics of secondary diabetes induced by 5-Fluorouracil (5-FU)-based chemotherapy in non-diabetic patients with colorectal cancer (CRC).Method: 422 consecutive CRC patients who received 5-FU-based chemotherapy were retrospective analyzed. Fasting plasma glucose (FPG) levels were determined before each cycle of chemotherapy during active treatment and regular follow-up. The prevalence and characteristics of secondary hyperglycemia were investigated, with special focus on the clinical outcomeResults: Among the 422 CRC patients, 60 had pre-existing hyperglycemia. In the remaining 362 with normal FPG levels before chemotherapy, 42 (11.6%) and 41 (11.3%) patients developed diabetes and impaired fasting glucose (IFG) during the study period. Among the 42 secondary diabetic patients, 22 (52.4%) received anti-diabetes drug therapy, in 7 (16.7%) cases the FPG level returned to normal without any active intervention, and 13 (30.9%) cases received diet control and physiotherapy. Thirty one (8.6%) patients developed diabetes. Based on Common Terminology Criteria for Adverse Events (CTCAE) criteria, an adverse effect (AE) over Grade 3 occurred in seven cases during follow-up. Diabetes-related AE had a serious negative impact on chemotherapy in six cases. Diabetes-related death occurred in three patients.Conclusions: Secondary diabetes associated with 5-FU-based chemotherapy occurs in around 10% of CRC patients, with a significant negative impact on treatment and clinical outcome. 5-FU-related diabetes should be regarded as a common side effect of 5-FU treatment.© 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland
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Deviation and failure of Enhanced Recovery After Surgery (ERAS) following laparoscopic colorectal surgery: early prediction model
Aim: Enhanced Recovery After Surgery (ERAS) programmes are well established, but deviation from the postoperative elements may result in delayed discharge. Early identification of such patients may allow remedial action to be taken. The aims of this study were to investigate factors associated with delayed discharge and to produce a predictive scoring system for ERAS failure.Method: A retrospective review was carried out of case notes of patients who underwent elective laparoscopic colorectal resection and ERAS at Yeovil District Hospital between 2002 and 2009. Univariate and multivariate analyses were performed and binary logistic regression was used to model a predictive scoring system.Results: 385 patient records were reviewed with a median length of stay of 6 days. 122 (31%) patients stayed longer than one week (delayed discharge) and 159 (41%) deviated in up to two postoperative ERAS factors. Patient demographic factors were not predictive of delayed discharge. Deviation from ERAS factors at the end of the first postoperative day, including continued intravenous fluid infusion, lack of functioning epidural, inability to mobilise, vomiting requiring nasogastric tube insertion and re-insertion of urinary catheter, were strongly associated with delayed discharge. A five element predictive scoring system for ERAS failure and delayed discharge was formulated.Conclusion: Enhanced recovery failure and delayed discharge after laparoscopic colorectal surgery can be predicted by the early deviation from postoperative factors of an ERAS programme.© 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland
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Inflammatory Bowel Disease. An Evidence Based Practical Guide
This book delivers a succinct evidence-based guide on the management of patients with Inflammatory Bowel Disease. (IBD). It comprises three principal sections, focusing on the management of ulcerative colitis and Crohn’s disease with a final section that addresses, “current issues and other scenarios”.© 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland
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Partial longitudinal resection of the anorectum and sphincter for very low rectal adenocarcinoma: a surgical approach to avoid permanent colostomy
Aim Abdominoperineal resection has been the standard procedure for low rectal cancer. The present study details a new technique, partial longitudinal resection of the anorectum and sphincter, and assesses the oncological and functional outcomes.Method Between January 2004 and April 2008, 12 patients underwent partial longitudinal resection of the anorectum and sphincter for low rectal cancer. All patients underwent a diverting ileostomy and received biofeedback training before stoma closure. Functional results were assessed by vector manometry, Wexner constipation score and Wexner incontinence score. The quality of life (QoL) was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30).Results There was no postoperative mortality and a R0 curative resection was confirmed in every case. Morbidity included anastomotic leakage in three patients, one of whom underwent reoperation, and stenosis in 11, which was successfully managed with dilatation. The patient who underwent reoperation was not included in the functional analysis. The 11 successful patients received biofeedback training for 1–4 months, and underwent ileostomy closure 6–12 months after surgery. No patient had severe faecal incontinence after stoma closure. The EORTC QLQ-C30 global health status and QoL scores at 12 months after stoma closure were 50.4 ± 24.3, similar to preoperation scores of 52.3 ± 25.6 (P = 0.927), and not significantly different to scores for the healthy control population of 63.4 ± 23.5 (P = 0.539). No patients developed local recurrence during the median observation period (35.5 months). One patient had distant metastases at 24 months, and underwent resection of the left liver.Conclusion Curability and acceptable anal function can be obtained by partial longitudinal resection of the anorectum and sphincter in patients with very low rectal cancers. This technique is recommended as an alternative to abdominoperineal resection in patients with external sphincter muscle invasion or tumours located below the dentate line.
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Role of biopsies in patients with residual rectal cancer following neoadjuvant chemoradiation after downsizing: can they rule out persisting cancer?
Aim The study aimed to determine the value of postchemoradiation biopsies, performed after significant tumour downsizing following neoadjuvant therapy, in predicting complete tumour regression in patients with distal rectal cancer.Method A retrospective comparative study was performed in patients with rectal cancer who achieved an incomplete clinical response after neoadjuvant chemoradiotherapy. Patients with significant tumour downsizing (> 30% of the initial tumour size) were compared with controls (< 30% reduction of the initial tumour size). During flexible proctoscopy carried out postchemoradiation, biopsies were performed using 3-mm biopsy forceps. The biopsy results were compared with the histopathological findings of the resected specimen. UICC (Union for International Cancer Control) ypTNM classification, tumour differentiation and regression grade were evaluated. The main outcome measures were sensitivity and specificity, negative and positive predictive values, and accuracy of a simple forceps biopsy for predicting pathological response after neoadjuvant chemoradiotherapy.Results Of the 172 patients, 112 were considered to have had an incomplete clinical response and were included in the study. Thirty-nine patients achieved significant tumour downsizing and underwent postchemoradiation biopsies. Overall, 53 biopsies were carried out. Of the 39 patients who achieved significant tumour downsizing, the biopsy result was positive in 25 and negative in 14. Only three of the patients with a negative biopsy result were found to have had a complete pathological response (giving a negative predictive value of 21%). Considering all biopsies performed, only three of 28 negative biopsies were true negatives, giving a negative predictive value of 11%.Conclusion In patients with distal rectal cancer undergoing neoadjuvant chemoradiation, post-treatment biopsies are of limited clinical value in ruling out persisting cancer. A negative biopsy result after a near-complete clinical response should not be considered sufficient for avoiding a radical resection.
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ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections1
Aim Surgical site infection (SSI) remains a common postoperative morbidity, particularly in colorectal resections, and poses a significant financial burden to the healthcare system. The omission of mechanical bowel preparation, as is performed in enhanced recovery after surgery programmes, appears to further increase the incidence. Various wound protection methods have been devised to reduce the incidence of SSIs. However, there are few randomized controlled trials assessing their efficacy. The aim of this study is to investigate whether ALEXIS wound retractors with reinforced O-rings are superior to conventional wound protection methods in preventing SSIs in colorectal resections.Methodology Patients undergoing elective open colorectal resections via a standardized midline laparotomy were prospectively randomized to either ALEXIS or conventional wound protection in a double-blinded manner. A sample size of 30 in each arm was determined to detect a reduction of SSI from 20% to 1% with a power of 80%. Secondary outcomes included postoperative pain. The operative wound was inspected daily by a specialist wound nurse during admission, and again 30 days postoperatively. Statistical analysis was performed using spss version 13 with P < 0.05 considered significant.Results Seventy-two patients were recruited into the study but eight were excluded. There were no SSIs in the ALEXIS study arm (n = 34) but six superficial incisional SSIs (20%) were diagnosed in the control arm (P = 0.006). Postoperative pain score analysis did not demonstrate any difference between the two groups (P = 0.664).Conclusion The ALEXIS wound retractor is more effective in preventing SSI in elective colorectal resections compared with conventional methods.
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Does the magnetic anal sphincter device compare favourably with sacral nerve stimulation in the management of faecal incontinence?
Aim The magnetic anal sphincter (MAS) is a recent surgical innovation for severe faecal incontinence (FI). With its place in the treatment algorithm of FI yet to be defined, we report a nonrandomized comparison between MAS and sacral nerve stimulation (SNS) in a single-centre cohort of patients with FI.Method Data were reviewed from prospective databases. From December 2008 to December 2010, 12 women [median age 65 (42–76) years], having FI for a median of 6.5 years, were implanted with a MAS. Sixteen women, of similar age, preoperative function scores, aetiology and duration of incontinence, and implanted with a permanent SNS pulse generator during the same period, served as a reference group. The duration of hospital stay, complications, change in incontinence and quality of life scores and anal physiology were compared between the two groups.Results The duration of follow up was similar [MAS = 18 (8–30) months vs SNS = 22 (10–28) months; P = 0.318]. Four patients with MAS experienced a 30-day complication, and the device was removed from one patient in each group. A significant improvement in incontinence (P < 0.001) and quality-of-life scores (P < 0.04) occurred in both groups. Mean anal resting pressure increased significantly in patients implanted with a MAS (P = 0.027).Conclusion In this single-centre nonrandomized cohort of FI patients, MAS was as effective as SNS in improving continence and quality of life, with similar morbidity. These results can now serve as a prelude to a randomized trial comparing the procedures.
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Implications of sentinel lymph node mapping on nodal staging and prognosis in colorectal cancer
Aim Sentinel lymph node (SN) mapping for staging in colorectal cancer remains controversial and needs to be validated before it can be implemented in daily practice. We prospectively assessed the effect of SN mapping on nodal staging and its implication on survival in patients with colorectal cancer.Method Between November 2005 and July 2009, 331 patients underwent a resection for colorectal cancer. In 189 patients (group A) an ex-vivo SN procedure was performed with immunohistochemical analysis of the SN. Tumour cell deposits between 0.2 mm and 2.0 mm were referred to as micrometastases (pN1mi+). The remaining patients (n = 142, group B) had standard nodal staging. Multivariate Cox regression analysis was performed to identify prognostic factors for disease recurrence.Results The average number of harvested lymph nodes was higher in group A than in group B (15.5 ± 7.3 vs 12.1 ± 5.2, P < 0.0001). After conventional staging, 81 (43%) patients of group A were judged to have nodal metastasis. This increased to 89 (47%) patients when immunohistochemically detected micrometastases were included. In group B, 50 (35%) patients had nodal metastasis. During follow up, a lower recurrence rate was seen in N0 patients after SN mapping compared with the conventional staging group (4%vs 15.2%, P = 0.04). The SN procedure (hazard ratio = 4.1) was an independent predictor of disease recurrence.Conclusion The SN procedure results in a more accurate staging of patients with colorectal cancer. This is reflected by a better prognosis of N0 patients after SN mapping.
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Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly
Aim Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients.Method This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients’ characteristics and presentation. Univariate and logistic regression analyses were performed on morbidity and mortality risk factors.Results Two-hundred and fifteen patients of > 65 years of age were included, 93 of whom were ≥ 80 years of age. The global mortality rate was 16%. In patients ≥ 80 years of age the mortality rate was 30%. The difference in mortality rate between patients < 80 years of age vs patients ≥ 80 years of age was 24%. In resected patients ≥ 80 years of age, American Society of Anesthesiology grade, colonic ischaemia, neurological comorbidity and anastomotic dehiscence were identified as independent risk factors in both univariate and logistic regression analyses. The morbidity rate was approximately 17%, and no significant difference in morbidity was found between the two groups.Conclusion The results of this study show that fitness status and micro vascular impairment impact significantly on mortality in the elderly, particularly in octogenarians. Although the outcomes observed were compatible with the literature, the six fold higher mortality rate observed in the most elderly patients identifies a group for which death prevention is best achieved with aggressive resuscitation and intensive postoperative care, rather than timing of surgery.
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Elective sigmoid colectomy for diverticular disease. Laparoscopic vs open surgery: a systematic review
Aim A meta-analysis of nonrandomized studies and one randomized trial was conducted to compare laparoscopic surgery with open surgery in the elective treatment of patients with diverticular disease.Method Published randomized and controlled clinical trials that directly compared elective open (OSR) with laparoscopic surgical resection (LSR) in patients with diverticular disease were identified using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. End-points included 30-day mortality and morbidity and were compared by determining the relative risk ratio, odds ratio, and the absolute effects.Results Eleven nonrandomized studies of 1430 patients were identified and included in the meta-analysis. There was only one randomized study, which included 104 patients. The meta-analysis suggested that elective LSR was a safe and appropriate option for patients with diverticular disease and was associated with lower overall morbidity (P = 0.01) and minor complication rate (P = 0.008).Conclusion The results of the nonrandomized study generally agreed with those of the randomized study, except for the incidence of minor complications, which was higher in both the LSR and OSR groups of the randomized study. In this study, the high overall morbidity of 42.3% reported in the LSR group is a cause for concern.
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Long-term quality of life in patients with permanent sigmoid colostomy
Aim The study aimed to assess quality of life (QoL) in patients with a sigmoid colostomy using a simple general and disease-specific instrument. A subgroup not doing well was identified and examined further.Method The Short Health Scale (SHS) is a four-item instrument exploring severity of symptoms, function in daily life, worry, and general well-being, using visual analogue scales ranging from 0 to 100 where 100 is the worst possible situation. The SHS was delivered to 206 patients with a sigmoid colostomy. It was returned by 181 (87.9%) patients [88 men; median age 73 (33–91) years]. Follow-up was 61 (10–484) months for 178 (86.4%) patients returning usable questionnaires. A subgroup of 16 patients scoring more than 50 in all four items of the SHS was further examined with StomaQOL where 100 is best possible.Results The median score for severity of symptoms was 18 (2–95), function in daily life 21 (0–95), worry 17 (3–98) and general well-being 22 (0–99). A score of < 50 in the SHS was recorded in 84.9%, 82.1%, 79.9% and 70.5% respectively. In the group scoring more than 50 in all four items patients diagnosed with irritable bowel syndrome constituted 43.8% to compare with 5.6% in the entire study group (P < 0.001). Median score for StomaQOL was 37 (22–62) in this group.Conclusion Most patients with a permanent sigmoid colostomy have a good QoL consistent with previous findings. However, this is reduced in a subgroup of patients diagnosed with irritable bowel syndrome.
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Pulmonary staging in colorectal cancer: a review
Aim Assessment of the chest in colorectal cancer (CRC) staging is variable. The aim of this review was to look at different chest staging strategies and determine which has the greatest efficacy.Method A review of studies assessing chest staging modalities for patients with CRC was performed. Modalities included chest X-ray (CXR), CT and positron emission tomography (PET).Results The majority of data consisted of case series. Two studies identified a low pick-up rate for CXR as a staging tool. Five studies showed increased detection rates of pulmonary metastases for chest CT vs CXR and abdominal CT. The clinical benefit of the increased detection rates was not clear. The incidence of indeterminate lung lesions (ILL) on staging chest CT varied from 4 to 42%. The majority (≥ 70%) of ILLs did not have any clinical significance. On CT scans, the incidence of pulmonary metastases in patients with rectal cancer ranged from 10 to 18% and in patients with colon cancer the incidence of pulmonary metastases ranged from 5–6%. The incidence of synchronous liver and pulmonary metastases compared with the overall incidence of pulmonary metastases ranged from 45 to 70%. There was no evidence reporting the superiority of PET/CT vs CT for the detection of pulmonary metastases or characterization of ILL.Conclusion Studies show that chest CT scanning increases the detection rates for ILL and pulmonary metastases. The clinical benefit of the increased detection rates is not clear. There is a paucity of data assessing the optimal chest staging strategy for patients presenting with CRC.
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Rectovesical fistula secondary to B-cell lymphoma of the rectum: a unique presentation of a rare disease
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Lymph node harvest in colorectal cancer
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Colorectal cancer incidence and trend in UK South Asians: a 20-year study
Aims South Asians comprise 13.6% of the Wolverhampton population. We aimed to compare the incidence and trend of colorectal cancer in this subgroup with the non South Asian population over a 20-year period.Method Patients of South Asian origin diagnosed with colorectal cancer from 1989 to 2008 were identified from the hospital histopathology database and compared with those of non South Asian origin. 1991 and 2001 census data were used to standardize for differing age and sex distributions in the two study populations.Results The median unadjusted incidence of colorectal cancer from 1989 to 2008 was 6.17 per 100 000 per year in South Asians compared with 71.70 per 100 000 per year in non South Asians (77.79% white British). The age and sex adjusted odds ratio for colorectal cancer in South Asians was 0.2 (P < 0.001). There was an equal increased trend in the incidence in both the South Asians and non South Asians over the study period (0.8% per year). In patients < 50 years, the gender difference in the incidence of cancer was not significant, but as age increased this rose significantly (males > females).Conclusion There was a markedly lower incidence of colorectal cancer in South Asians compared with non South Asians, maintained over 20 years. Colorectal cancer incidence increased by a small and similar amount over the period in both groups. There was a male preponderance of colorectal cancer in both populations over 50 years.
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To cut or to daub? An algorithmic approach to anal fissure
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Anal duplex fails to show changes in vascular anatomy after the haemorrhoidal artery ligation procedure
Aim The aim of this prospective study was to evaluate whether the beneficial effect of haemorrhoidal artery ligation/transanal haemorrhoidal dearterialization (HAL/THD) is attributable to a change in the vascular anatomy at the level of the corpus cavernosum recti.Method Patients treated by HAL/THD for Grade II or Grade III haemorrhoids were scanned by anal colour Doppler endosonography before treatment and 6 weeks postoperatively. As part of a randomized controlled trial, patients were treated either with or without the Doppler scan. The number and diameter of vascular structures were measured at the distal, mid and proximal levels in the anal canal.Results There were 30 patients in the non-Doppler group and 34 in the Doppler group. The postoperative measurements of the anal colour Doppler endosonography did not show any significant differences in vascular anatomy compared with the preoperative measurements, regardless of whether the Doppler probe was used (P > 0.05).Conclusion This study failed to show that the effect of HAL/THD is caused by alteration of the macroscopic vascular anatomy in the corpus cavernosum recti.
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Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review
Aim The long-term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect.Method The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow-up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life.Results Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies.Conclusion Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long-term follow-up, although beset with difficulties, should be conducted.
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