ENTERAL VERSUS PARENTERAL NUTRITION AFTER OESOPHAGOGASTRIC SURGERY: A PROSPECTIVE RANDOMIZED COMPARISON

Background: There appears to be an emerging consensus that early postoperative nutritional support benefits the high-risk patient by decreasing septic morbidity, maintaining immunocompetence and improving wound healing. Enteral nutrition via a feeding jejunostomy has been associated with serious complications, with a reported mortality rate as high as 10%. while total parenteral nutrition has also been associated with a wide variety of complications. Methods: Ninety-seven patients undergoing oesophagectomy or gastrectomy underwent pre-operative nutritional assessment and were randomized to receive either total parenteral nutrition (47 patients) or enteral nutrition (50 patients). Results: There was no significant difference in the number of catheter-related complications between the two groups, but 9 (45%) patients in the total parenteral nutrition group had major morbidity (potentially fatal in two patients) requiring active intervention. Conclusions: This study demonstrates enteral nutrition to be safe and associated with mainly reversible minor complications. It is probable that immediate postoperative enteral feeding conserves the gut's integrity. Whether this leads to a reduction in postoperative septic complications has not been demonstrated by this study although there appears to be a trend in this direction, supporting the concept of enteral feeding as ‘primary therapy’. This can be safely, simply and economically achieved using a feeding jejunostomy placed at the time of surgery.     

A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPARING SUPRAPUBIC WITH URETHRAL CATHETERIZATION IN RECTAL SURGERY

Background : Bladder drainage is necessary for several days following rectal surgery. Urethral catheterization has long been known to be associated with significant morbidity. Therefore a prospective randomized trial was performed to determine if this morbidity could be decreased by suprapubic catheterization. Methods : One hundred and thirty-seven patients undergoing rectal surgery were prospectively randomized to either suprapubic or urethral catheterization. Results : After exclusions, 108 patients were analysed. Of the 49 patients with suprapubic catheters there was 14% morbidity, and of the 59 patients with urethral catheters there was 32% morbidity. Significant bacteriuria was halved with suprapubic catheterization. Patient acceptability of suprapubic catheterization was high, and there was no increased morbidity in any of the areas studied. Conclusions : This study suggests that suprapubic catheterization has advantages over urethral catheterization with decreased bacteriuria, and greater patient acceptability. However, the significance of decreased bacteriuria is not clear and therefore we can only say suprapubic catheter drainage is comparable to urethral catheter drainage.     

EARLY DISCHARGE AFTER OPEN APPENDICECTOMY

Background: There is increasing pressure on surgeons to minimize the time patients stay in hospital, and there is therefore a need to establish guidelines for reasonable lengths of stay for common operations. This study was conducted to test the feasibility and safety of early discharge after open appendicectomy. In addition, this study was performed to provide standards for open appendicectomy against which the results of laparoscopic appendicectomy can be compared. Methods: A prospective study of all patients having open appendicectomy for suspected acute appendicitis at Liverpool Hospital, Sydney during a 4 month period was undertaken. An early discharge programme was established, with the aim of discharging patients within 48 h of operation in uncomplicated cases. Discharge was allowed when the patient was eating, walking, and had passed flatus. Follow up was with the consultant surgeon at I week postoperatively, and with a community nurse at 2 weeks. Multivariate linear regression, using the number of postoperative hours to discharge as the outcome, was used to analyse the data for the following four factors: age, gender, incision type, and pathology. Results: One hundred and sixteen consecutive patients were enrolled in the study. The median postoperative stay for all patients was 46 h. Perforation of the appendix, use of a midline laparotomy for appendicectomy, and age significantly prolonged hospital stay, but gender had no effect. The main complication was wound infection, which was seen in 7.5% of patients. No patient had a problem directly related to early discharge. A community nurse saw 81% of patients 2 weeks after discharge. Over three-quarters of the patients seen had returned to full normal activities by 2 weeks, including work or school. Eighty-eight per cent of patients considered the timing of their discharge ‘good’ or ‘excellent’. Conclusions: Discharge at 2 days after open appendicectomy is both feasible and safe for patients having an unperforated appendix removed through a right iliac fossa incision. Passage of stool is not required prior to discharge. Early discharge is well accepted by patients and may result in financial savings for hospitals where payment is according to Diagnosis-Related Groups. On the basis of the results of the six randomized controlled trials comparing laparoscopic and conventional open appendicectomy published to date, and on the results of this study, the authors conclude that laparoscopic appendicectomy should not yet be considered the ‘procedure of choice’, and surgeons are justified in performing appendicectomy by either method.     

A PROSPECTIVE TRIAL OF OPEN VERSUS LAPAROSCOPIC APPENDICECTOMY

Background: An assessment of the value of laparoscopic appendicectomy was performed. Methods: During 1993, all patients above the age of 13 years admitted with clinical appendicitis to Box Hill Hospital were assigned to an open or laparoscopic procedure depending on whether the surgeon on call was an ‘open’ or ‘laparoscopic’ surgeon for the purpose of the study. Ninety-two patients were entered in the study, of whom 57 were in the open group. The rate of histologically proven appendicitis was 73.9%. Results: No significant difference between the groups was found in the use of narcotic analgesia, length of stay or incidence of wound infection. However, operating time was significantly longer in the laparoscopic group. Conclusions: Laparoscopic appendicectomy on an unselected group of patients does not confer many advantages but laparo-scopy may be beneficial in certain subgroups.     

HOLMIUM LASER VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: A RANDOMIZED PROSPECTIVE TRIAL WITH 1-YEAR FOLLOWUP

PURPOSE: The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. RESULTS: Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. CONCLUSIONS: Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.     

INTRARECTAL LIDOCAINE DURING TRANSRECTAL PROSTATE BIOPSY: RESULTS OF A PROSPECTIVE DOUBLE-BLIND RANDOMIZED TRIAL

PURPOSE: Recent reports have indicated the benefit of anesthesia during prostate biopsy. To assess this finding objectively we performed a prospective randomized double-blind study to compare patient pain with and without local anesthesia during transrectal ultrasound guided prostate biopsies. MATERIALS AND METHODS: Between August 2000 and March 2001, 108 men undergoing transrectal ultrasound guided biopsy of the prostate were randomized in double-blind fashion to receive intrarectal 2% lidocaine gel or intrarectal lubricant alone. No patient received pre-procedure narcotics or sedation. Pain associated with biopsy was determined using a horizontal linear visual analog pain scale. Pain scores in the 2 treatment groups were compared and possible predictors of increased pain were examined. RESULTS: The 2 groups were similar in demographic characteristics. There was no significant difference in pain score in the 2% lidocaine and lubricant alone groups (28.3 versus 28.9 mm., p = 0.88). Previous biopsy, time since previous biopsy, physician, number of biopsies and prostate volume did not correlate with pain score, while age correlated negatively with the score (r = -0.27, p = 0.005). A single complication involving a vasovagal episode resolved spontaneously. CONCLUSIONS: Intrarectal lidocaine gel provides no significant therapeutic or analgesic benefit compared with lubricant alone for transrectal ultrasound guided biopsy of the prostate. In younger patients more discomfort is associated with this procedure.     

LYMPHOCYTE SUBPOPULATION AND NATURAL KILLER CELL CYTOTOXICITY AFTER LAPAROSCOPIC ASSISTED RESECTION OF RECTOSIGMOID CARCINOMA—A PROSPECTIVE RANDOMIZED TRIAL

We compared the lymphocyte subpopullation and natural killer cell cytotoxicity in patients after laparoscopic assisted resection with those after open resection of rectosigmoid carcinoma. Background: Laparoscopic assisted resection of colorectal carcinoma is technically feasible and less traumatic, the postoperative immunosuppression thus may be reduced and potentially beneficial to tumour surgery. Methods: Forty patients with rectosigmoid carcinoma, without evidence of metastatic disease and suitable for laparoscopic assisted resection were randomized to receive either laparoscopic assisted (20 patients) or conventional open (20 patients) resection of the tumour. Clinical parameters were recorded. Blood were collected before operation, 24 hours, 72 hours and 8 days after operation for lymphocyte subsets and natural killer (NK) cell cytotoxicity studies. Data were analyzed by intention to treat. Results: The demographic data of the two groups were comparable. Clinically the laparoscopic group had significantly earlier return of bowel function, earlier mobilization and required less analgesia. The lymphocyte subpopulations and NK cell cytotoxicity of both groups showed a typical suppression after surgery. The suppression of T cell activation and NK‐like T cells was significantly less after laparoscopic assisted resection than in the open group, while the difference in other lymphocyte subpopulation and NK cell cytotoxicity were not significant. Conclusion: This study showed that some cellular components of immune system were less suppressed after laparoscopic assisted than conventional open resection of rectosigmoid carcinoma. This may have implication on the patient survival.     

RANDOMIZED CONTROLLED TRIAL COMPARING SAME-DAY DISCHARGE WITH HOSPITAL STAY FOLLOWING HAEMORRHOIDECTOMY

Background: A randomized controlled trial was conducted to compare traditional hospital stay haemorrhoidectomy (STAY) with same-day discharge haemorrhoidectomy (DAY) with regard to costs, clinical outcome and patient satisfaction. Methods: A total of 54 consecutive patients were randomized to either STAY or DAY groups. A standardized excision of three piles was performed and the wounds were left open. The DAY patients went home on the same day but the STAY patients remained in hospital until their bowels had opened. A linear analogue pain score and patient satisfaction questionnaire were administered. During a mean follow-up of 60.5 (standard error of mean =1.2) weeks, the complications and the total medical costs were recorded. Results: There were no differences in the age and sex distributions in both groups (STAY: 11 men, 16 women; mean age 40.6 (± 1.8) years; DAY: 10 men, 17 women; mean age 40.6 (± 1.9) years). Despite accounting for any readmissions, the DAY patients accumulated shorter total hospitalization stays (P < 0.001) and incurred less total medical costs (P= 0.04). The pain scores, analgesia requirements, postoperative complications, patient satisfaction and time taken off work were not different between the two groups. However, more patients in both groups preferred to stay after surgery if they should need another haemorrhoidectomy. Conclusions: Haemorrhoidectomy (with excision of three piles) can be safely performed as a day procedure, with reduced hospitalization and medical costs.     

围术期输血对结,直肠癌术后感染发生的影响

本文对２１８例结、直肠癌手术病人进行观察以探讨术后感染并发症发生的围术期影响因素。结果发现，围术期输血与术后感染发生呈非常显著的正相关关系（Ｐ＜０．００１），１４２例接受输血的病人有５０例发生术后感染（３５％），而７６例未接受输血的病人只有６例（８％）出现术后感染。病人年龄、性别、失血量、手术方式、肿瘤分化程度、血红蛋白含量、手术时间等因素与术后感染发生均无明显相关关系（Ｐ＞０．０５）。提示围术期输血是引起结、直肠癌术后感染发生的独立的重要危险因素。     

COLORECTAL CANCER AT THE PRINCESS ALEXANDRA HOSPITAL: A PROSPECTIVE STUDY OF 729 CASES

The results of treatment of 729 patients with cancer of the large bowel treated at the Princess Alexandra Hospital from January 1971 to December 1980 have been analysed. The majority (540 patients or 74.1%) presented with symptoms requiring investigation, and there was an incidence of acute obstruction of 17.6% (128 patients). In just over half the patients (55.3%) there was a significant delay in diagnosis. The operative mortality rate for curative resections for both rectal and colonic cancer was 2.7%. There was no mortality in 24 curative local resections for rectal cancer. The resection rate for the whole group was 87.4% and the age corrected 5-year survival rates were Dukes’A 99.1%; Dukes’B 78.3%; and Dukes’C 32.4%. These results are compared with those reported in a retrospective study from this Hospital in 1975 and with those from other Australian and overseas centres.     

MECHANICAL PERCUSSION, INVERSION AND DIURESIS FOR RESIDUAL LOWER POLE FRAGMENTS AFTER SHOCK WAVE LITHOTRIPSY: A PROSPECTIVE, SINGLE BLIND, RANDOMIZED CONTROLLED TRIAL

PURPOSE: We compare the effectiveness of mechanical percussion and inversion with observation for eliminating lower caliceal fragments 3 months after shock wave lithotripsy. MATERIALS AND METHODS: At 3 months after shock wave lithotripsy 69 patients with residual lower caliceal fragments 4 mm. or less were randomized to receive either mechanical percussion and inversion or observation for 1 month. The observation group then received crossover mechanical percussion and inversion if fragments persisted. All patients were followed with plain film of the kidneys, ureters and bladder to assess the stone area and stone-free status, and renal tomography or noncontrast spiral computerized tomography to confirm stone-free status. A blinded radiologist reviewed all films. Patients were treated with a mechanical chest percussor applied to the flank while inverted to greater than 60 degrees after receiving 20 mg. furosemide. RESULTS: A total of 35 patients were randomized to receive immediate mechanical percussion and inversion therapy and 34 observation. Of the patients in the observation group 28 subsequently received mechanical percussion and inversion after completing the observation period. The groups were not different in gender, body mass index, side affected, stone location or renal anatomical features. The mechanical percussion and inversion group had a substantially higher stone-free rate than the observation group (40% versus 3%, respectively, p <0.001). The mechanical percussion and inversion group also had a greater improvement in total stone area than controls (-63.3% versus +2.7%, respectively, p <0.001). No significant adverse effects were noted in the mechanical percussion and inversion group. CONCLUSIONS: Mechanical percussion and inversion is a safe and effective treatment option for residual lower caliceal fragments 3 months after shock wave lithotripsy. Nearly 50% of patients become stone-free, and stone burden is decreased by 50% in the remainder.     

INVESTIGATION,FOLLOW-UP AND RECURRENCE AFTER RESECTION OF COLORECTAL CANCER

A study was undertaken to determine the patterns of management in the 2 years following resection of colorectal cancer by Victorian surgeons. Patients were identified by the Victorian Cancer Register as having colorectal cancer diagnosed between 1 July and 31 December 1987. The surgeon of each of the 947 eligible patients who underwent surgery was sent a questionnaire seeking information about the pre-operative investigation. type of surgery and subsequent line of referral. Only 16% of colonic cancers and 39% of rectal cancers were biopsied pre-operatively and colonoscopy was undertaken in one-half and one-third respectively. Of the 737 responses, 555 patients were considered to have had curative surgery, and details of their follow-up during the four 6-month periods following surgery was analysed; this includes the effect of tumour stage and surgeon activity on the use and frequency of each test. Most patients had a clinical examination in each of the 6 month periods, but almost half did not have a colonoscopy and two-thirds did not have the serum CEA level measured at all. Only one in eight had a chest X-ray and fewer had the liver scanned during this 2 year period. Eighty-two patients (20% of those satisfactorily followed) suffered a recurrence during this period. Twenty-six were asymptomatic at the time of recurrence and were diagnosed by a routine test and of these, eight were diagnosed by tests used infrequently. Sixteen (20%) were considered surgically curable.     

THE MANAGEMENT OF COLORECTAL PERFORATION AND PERITONITIS

Background : Surgical outcomes in patients presenting with colonic perforation or peritonitis tend to be poor. This study was undertaken to determine outcomes in such patients at a time before multiple re-laparotomies were performed. Methods : Retrospective analysis of computer records of all patients presenting acutely to the University Surgical Unit (Wellington School of Medicine) with colonic perforation or peritonitis over a 15-year period. Results : Seventy-three patients, 33 males and 40 females were admitted with either perforation or localized peritonitis of colorectal origin. Of these, 78% were managed as emergencies, but six were admitted electively and found incidentally. Consultant surgeons performed surgery slightly more frequently than registrars. Two patients were managed non-operatively. Forty-one percent received peri-operative blood transfusion and 22% peri-operative total parenteral nutrition. The majority of patients presented with either peritonitis or free perforation in association with diverticular disease. The site of perforation was either ileocolic or sigmoid colonic in the majority of patients. Hartmann'operation was the most commonly performed resection. Respiratory, urinary and wound infections were the most commonly observed postoperative complications. Two patients developed anastomotic leaks (6.3%). The overall persistent intra-abdominal infection rate was 5.5%. Seven patients died following surgery. Conclusions : Resection of the perforated bowel is mandatory and this should be followed by anastomoses in the case of right-sided lesions and a Hartmann'operation or resection, colostomy and mucous fistula in distally situated lesions.     

USE OF A COTTON TAPE TIE IN LAPAROSCOPIC COLORECTAL SURGERY

In this short article we describe the use of a cotton tape tie in laparoscopic colorectal surgery. This technique is useful in: (i) retraction and manipulation of the bowel; (ii) exteriorization of a bulky specimen; and (iii) occlusion of the rectal lumen to permit effective cytocidal rectal lavage.     

COLORECTAL RESECTION IN VICTORIA: A COMPARISON OF HOSPITAL BASED AND INDIVIDUAL AUDIT

Background: The results of personal audit have not been tested against a hospital-based audit previously and the results of two such audits of colorectal resection in the State of Victoria have provided this opportunity. In addition, data reflecting the results of colorectal resection across a range of hospitals and surgeons in the Victorian community have been obtained. Methods: A total of 535 patients undergoing a colorectal resection, with an anastomosis performed, were studied in two serially conducted prospective audits arranged by the Standards Sub-committee of the Victorian State Committee. One study was public hospital-based and the second was based on voluntary reporting by individual surgeons. Results: Similar results were obtained in each study, demonstrating the accuracy of individual reporting. The combined results (wound infection rate 12.3%. anastomotic leak rate 3.7% and mortality 4.5%) are compared to previously published data. Conclusions: In the State of Victoria the results of audit by individual surgeons performing colorectal resection were similar to the hospital-based audit. The results obtained compare favourably with previously published data.     

COLORECTAL SURGERY IN THE ELDERLY: AN AUDIT OF SURGERY IN OCTOGENARIANS

Background : Morbidity and mortality rates are higher in elderly compared to younger patients undergoing colorectal cancer surgery. This study was undertaken to see whether this finding applied to all colorectal surgery in the elderly and if so to try to identify the determining factors. Methods : All patients undergoing colorectal surgery between 1975 and 1990 were entered into a computerized database. Patients were divided into two groups, those less than 80 years (< 80) and those 80 years and more (80+), and compared with regard to the type of surgery performed, the patient's race, the seniority of the surgeon, the patient's disease, the operation performed and the postoperative morbidity and mortality. In addition, patients undergoing major resectional surgery and patients undergoing colorectal cancer surgery were compared separately. Results : Of 2011 admissions, 88 were for patients of 80+. The male to female admission rate was 1: 0.79 in the < 80 group and 1: 1.25 in the 80+ group. More surgical procedures were performed by consultants in older patients. More emergency admissions were for 80+ patients. Rectal, sigmoid and right colonic pathology was more common in the elderly. Very few elderly patients were admitted with minor anorectal problems. Rectal prolapse and colorectal cancer were the commonest causes for admission in octogenarians. There were more pulmonary and cardiovascular postoperative complications in 80+ patients. Urinary tract infections were also more common. The postoperative mortality rate was higher in older patients (7.9 vs 1.4%). Four hundred and sixty-two patients underwent major resectional surgery and 45 were 80+. Surgery for diverticular disease was more frequent in younger patients (13.4 vs 2.2%) and cancer surgery in older patients (93.3 vs 70.5%). The postoperative mortality rate was higher in the elderly (11.1 vs 3.6%). Three hundred and thirty-six major resections were for cancer and 42 were 80+. Emergency surgery was performed more commonly in the older group (38.1 vs 14.9%). The rate of advanced disease seemed to be similar in both groups. The postoperative death rate was higher in the elderly (11.9 vs 3.4%). Conclusions : Elderly patients were more likely to die from cardiopulmonary problems after surgical interventions than either from their primary disease or from the surgery undertaken for it. Good postoperative cardiopulmonary support should thus be provided for all such patients.