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   Table of Contents - Current issue
April-June 2019
Volume 8 | Issue 2
Page Nos. 35-64

Online since Thursday, June 27, 2019

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Curative management of malignant left-sided colorectal obstruction p. 35
Wen-Shen Lee, Joseph C Kong, Peter Carne, Stephen Bell, Satish K Warrier
Left-sided malignant colonic obstruction remains a challenging surgical problem despite recent advances. We aim to provide a concise overview of the relevant surgical options for this condition in the curative setting. A literature search of MedLine, PubMed, and Embase was performed to elucidate the latest evidence in the management of malignant left-sided colorectal obstruction, focusing on the risks and benefits of each approach and the appropriate patient selection. Primary resection and anastomosis are the intervention of choice for low-risk patients in the curative setting. Delayed resection with a bridge to surgery should be considered in unwell patients requiring medical optimization. While stenting has gained popularity, the risk of stent perforation carries a poor prognosis and must be carefully considered. Hartmann's procedure should be considered in high-risk elderly patients. Subtotal colectomy is preferred over segmental colectomy when there is extensive proximal colon damage but results in more frequent bowel actions postoperatively.
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Trends in survival after colorectal cancer surgery in an Australian regional hospital p. 40
Suat Chin Ng, Douglas Stupart, David Watters
Background: Colorectal cancer(CRC) is the second most common cancer in Australia. Improvements in patient outcomes after resections for CRC have been reported in an Australian metropolitan hospital, but significant outcome variability exists between health systems and institutions. Objective: This study sought to determine whether changes in the management of CRC have translated into improved survival after surgery in an Australian regional hospital. Design: This is a retrospective study of a prospectively maintained database. Setting: This study was conducted in an Australian regional hospital. Patients and Methods: All patients who underwent surgery for CRC at our institution between January 2002 and December 2014 were studied. Demographic information, comorbidities, types of surgery performed, and tumor staging were recorded. Patients were followed up for life whenever possible. Survival analysis was done using the Kaplan–Meier method, and comparisons made using the Cox proportional-hazards method. Chi-squared test was used to compare categorical data and look at trends as appropriate. P ≤ 0.05 was considered statistically significant. Statistical analysis was done using Medcalc®(Mariakerke, Belgium) software. Main Outcome Measures: Primary outcome measures the survival trends for CRC patients in regional center, Victoria. Secondary outcomes measure the short-term results, including perioperative mortality and anastomotic leak rate. Sample Size: A total of 1079patients who underwent surgery for CRC over13years were studied. Results: There were 744 colon cancer and 335 rectal cancer patients. The number of operations per year increased over time(P=0.037). The median age was 72years(range, 23–98) and this did not change over time(P=0.67). There was also no temporal change in tumor stage distribution(P=0.21) or in the proportion of emergency cases(P=0.75), but the proportion of patients with severe comorbidities increased(P=0.015). The perioperative mortality rate was 4.5%. The median survival after surgery by stage was 123months(Stage I), 141months(Stage II), 76months(Stage III), and 17months(Stage IV tumors). Over the study period, there were improvements in both perioperative mortality(P=0.028) and long-term survival(P=0.0025). Conclusion: Both short-and long-term survivals after surgery for CRC have improved in our institution. Limitation: Although a large regional cohort was analyzed, the study still has its own limitation, in that it is a retrospective single institute study.
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Current status of robotic colorectal surgery in Australasia: Aquestionnaire survey of consultant members of the colorectal surgical society of Australia and NewZealand p. 44
Kenneth N Buxey, Francis F Lam, Graham L Newstead
Background: There has been considerable interest worldwide in the application of a robotic operating platform in the practice of colorectal surgery. Objective: The aim of this study was to evaluate the current uptake of robotic colorectal surgery in Australia and NewZealand. Design: Survey data were obtained from the Colorectal Surgical Society of Australia and NewZealand(CSSANZ) registry of all specialist colorectal surgeons in Australia and NewZealand. Setting: Specialist colorectal surgeons responded to the survey through e-mail contact via an official e-mail from the CSSANZ. Materials and Methods: A questionnaire was distributed to members of the CSSANZ regarding their current robotic surgical practice. Main Outcome Measures: Volume of and nature of robotic surgery being currently undertaken in Australia and NewZealand, with an emphasis on seeking to understand the surgeon and patient factors that would promote robotic practice and also any factors or barriers in the implementation of robotic colorectal surgery being performed. Sample Size: The sample size was 77. Results: Seventy-seven replies were received from a total of 227 surveys. The response rate is similar to other comparable surveys published when the laparoscopic colorectal era was introduced. Most surgeons performed minimally invasive(laparoscopic) surgery; however, only 29% performed any robotic surgery and 50% of these performed<5cases in the preceding 12months. Low rectal cancer and rectopexy surgeries were the most frequently performed robotic operations. About 48% of surgeons believed that the robotic platform offers specific patient benefits, and 75% believed that it offers specific benefits to the surgeon. The main reason for consultants not performing robotic procedures was largely related to cost, with training also cited as a barrier. Conclusion: Robotic colorectal surgery is being performed by 29% of colorectal consultants in Australasia, although only a minority of these surgeons have a substantial volume. In the future, a substantial reduction in costs is envisaged, as more companies enter the robotic surgery marketplace and competition drives reduction in costs. This in many ways mirrors the introduction of laparoscopy and we believe as cost comes down, training pathways need to be established to train the next generation of colorectal surgeons robotically. Limitations: Our study is limited by inherent limitations of survey data and the response rate.
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Age versus American society of anesthesiologists–Examining 30-day mortality and morbidity in elderly patients undergoing colectomy from the American college of surgeons national surgical quality improvement program p. 47
Anne K Mongiu, Rowza T Rumma, Amy K Wise, Russell W Farmer
Background: As the percentage of the population that is elderly increases, colorectal operations performed in this age group are becoming more common. This study examined the use of the American Society of Anesthesiologists(ASA) Classification System(class) as a predictor of 30-day morbidity and mortality in patients≥90years old. Objective: The objective of this study was to evaluate the use of ASA classification in elderly patients undergoing colorectal surgery to determine whether it is an accurate predictor of perioperative risk. Design and Setting: This was a retrospective database review. Patients and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all colectomies, coloproctectomies, and proctectomies performed from 2005 to 2009. Demographic and perioperative information including class and 30-day outcomes were assessed. Amultiple logistic regression model was used to calculate the odds of 30-day morbidity and mortality correlated with age, class procedure type (open vs. minimally invasive), and do not resuscitate (DNR)status. Main Outcome Measures: 30-day mortality and 30-day morbidity. Sample Size: The sample size included 73,974patients. Results: Atotal of 73,974patients were identified including 1276patients≥90years old. Across all patients, multiple logistic regression demonstrated higher odds of 30-day mortality with increase in class(P < 0.001, odds ratio[OR] 5.62), age(P < 0.001, OR 1.04), DNR status(P < 0.001, OR 3.01), and open procedures(P < 0.001, OR 2.60). Subgroup analysis of patients with class≤3 showed increase in 30-day mortality with increased age(P < 0.001, OR 1.05), class(P < 0.001, OR 3.87), DNR status(P < 0.001, OR 5.05), and open procedures(P < 0.001, OR 2.39). For patients ≥90 with class≤3, class was no longer correlated with 30-day mortality(P = 0.251) or morbidity(P = 0.236). Conclusions: In colorectal surgery patients, class is a validated predictor of morbidity and mortality. For the most elderly patients, class indicative of preoperative status of less than a constant threat to life(≤3) increasing class does not correlate with increased morbidity or mortality. Ongoing work is needed to define predictors of risk in these patients. Limitations: This is a retrospective study derived on data retrieved from a national database; we are limited to the preselected variables collected and the potential for missed or omitted patients.
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CYP2C9 polymorphism is not associated with elevated carcinoembryonic antigen levels p. 54
Claire Hall, Rebecca Roberts, Tony R Merriman, Atanu Pal, Tim Eglinton, Chris Wakeman, Frank Frizelle
Background: Carcinoembryonic antigen (CEA) is a glycoprotein that can be elevated in a number of benign and malignant conditions. In colorectal cancer, it is used as a prognostic marker and to detect recurrence. However, it lacks specificity and may become elevated in individuals without a history of cancer or other identifiable cause leading to costly and invasive investigation. Objective: The aim of this study was to assess whether genetic polymorphisms in the liver enzyme CYP2C9 could explain high CEA levels in otherwise normal individuals. Design: This is a case-control study. Setting: Individuals were genotyped for the poor metabolizer (PM) alleles CYP2C9*2 and CYP2C9*3 using predesigned TaqMan single nucleotide polymorphisms assays. Patients and Methods: Nineteen individuals with previously clinically unexplained elevated CEA and 567 healthy Caucasian controls were included. Main Outcome Measures: Chi-square analysis was used to test for association of CYP2C9 genotype with plasma CEA concentration. Sample Size: Nineteen individuals with previously clinically unexplained elevated CEA and 567 healthy Caucasian controls were included. Results: Fifteen of the 19 individuals with previously high CEA had elevated plasma CEA (>3.0μg/L) on re-testing. The frequency of CYP2C9 PM alleles in these 15 patients was not significantly higher than the frequency in controls. Conclusion: CEA concentrations do not appear to be influenced by CYP2C9 genotype, so this cannot be used to explain elevated CEA in the absence of an obvious clinical cause. Limitation: Small sample size.
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Deadly if missed: Acase of recurrent perineal hernia mimicking as perineal cellulitis following abdominoperineal resection p. 58
Himeesh Kumar, Suat Chin Ng, Jonathan Y.J. Chua, Raaj Chandra
Perineal hernia is a rare condition most commonly described following abdominoperineal resection(APR). We report the case of a 71-year-old woman who presented with a third episode of strangulated perineal hernia mimicking perineal cellulitis following APR surgery. She underwent an emergency laparotomy, small bowel resection, and biological mesh repair. We further discuss the pros and cons of different surgical options available to surgeons when faced with this problem.
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Mixed adenoneuroendocrine tumor of the perianal skin p. 61
Daniel J Mullins, Robert T Lewis
Mixed adenoneuroendocrine carcinoma (MANEC) of the intestinal tract, is relatively rare and with a poor prognosis. The majority of literature to date has documented the rare occurrence of this tumor within the colon or rectum, but not within the anal canal or verge. We report our case of a female patient identified with a MANEC tumor of the perianal skin extending into the anal canal.
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Lecicarbon a suppositories: An acceptable bowel preparation for flexible sigmoidoscopy? p. 64
Caitlin M Brennan, Gordon A McFarlane, Louise M Robertson, Morag Douglas
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