Magnetic resonance imaging predicts circumferential resection margin status in patients receiving preoperative chemoradiotherapy for rectal cancer

Objective:  Advanced pelvic tumours require multidisciplinary care in order to improve outcome.
This is an audit of one specialist unit's experience.
Method:  Consecutive patients referred from 2001 to 2005 for consideration of pelvic clearance were evaluated by retrospective review.
Results:  Of 100 patients assessed, 55 were considered unsuitable for surgery. Exclusions included unresectable pelvic side-wall disease (25), widespread disease (23) and severe co-morbidity (7). Forty-five patients were operated on; 22 had locally advanced disease, 14 had recurrence and nine had residual disease following previous surgery. The primary cancers were colorectal in 24, gynaecological in 10 and urogenital in 10; one patient had nonneoplastic disease. Preoperatively 39 (87%) had examination under anaesthetic (87%) and all had MR and CT imaging. Neoadjuvant radiotherapy and chemotherapy was given in 27 and 18 patients respectively. Following resection by a multi-speciality team, surgery was considered curative in 40 (90%) of cases as judged by a histologically negative margin. All patients received level 2 care postoperatively with only two requiring level 3 care. There was no 30-day mortality but there were 17 complications treated conservatively and five that required surgery.
Conclusion:  Advanced pelvic tumours require careful multidisciplinary assessment and treatment. This study shows that this can be done safely with high levels of histological clearance of tumour.     

Rectal cancer: involved circumferential resection margin – a root cause analysis

Introduction  An involved circumferential resection margin (CRM) following surgery for rectal cancer is the strongest predictor of local recurrence and may represent a failure of the multidisciplinary team (MDT) process.
Aim of study  The study analyses the causes of positive CRM in patients undergoing elective surgery for rectal cancer with respect to the decision-making process of the MDT, preoperative rectal cancer staging and surgical technique.
Method  From March 2002 to September 2005, data were collected prospectively on all patients undergoing elective rectal cancer surgery with curative intent. The data on all patients identified with positive CRM were analysed.
Results  Of 158 patients (male:female = 2.2:1) who underwent potentially curative surgery, 16 (10%) patients had a positive CRM on postoperative histology. Four were due to failure of the pelvic magnetic resonance imaging (MRI) staging scans to predict an involved margin, two with an equivocal CRM on MRI did not have preoperative radiotherapy, one had an inaccurate assessment of the site of primary tumour and in one intra-operative difficulty was encountered. No failure of staging or surgery was identified in the remaining eight of the 16 patients. Abdominoperineal resection (APR) was associated with a 26% positive CRM, compared with 5% for anterior resection.
Conclusion  No single consistent cause was found for a positive CRM. The current MDT process and/or surgical technique may be inadequate for low rectal tumours requiring APR.     

The prognostic impact of pelvic lymph node metastasis and lymphovascular invasion on bladder cancer

Objectives:   To present long-term results of a single-center series of patients undergoing bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer and to analyze the impact of pelvic lymph node metastasis and lymphovascular invasion on clinical outcome.
Methods:   Between 1986 and 2005 833 patients were treated with bilateral pelvic lymphadenectomy and radical cystectomy at our institution. 614 of them with valid clinical follow-up information and no neoadjuvant therapy could be evaluated.
Results:   Disease-free and overall survival in the entire cohort was 56.7% and 49.5% at 5 years and 52.4% and 38.2% at 10 years, respectively. 28.1% of all patients had pelvic lymph node metastasis. We found organ-confined tumor stages (≤pT2) in 43.8%. Patients with non-organ-confined tumor stages (≥pT3) and positive pelvic lymph nodes had a significantly shorter overall survival than those without lymph node metastasis ( P  < 0.0001). In the subgroup of ≤pT2, the presence of pelvic lymph node metastasis did not show a statistically significant effect on overall survival ( P  = 0.618). The presence of lymphovascular invasion was associated with an impaired survival ( P  < 0.0001). In multivariate analysis, pathological tumor stage ( P  < 0.0001), lymph node stage (≥pT3) ( P  = 0.004) and lymphovascular invasion ( P  = 0.001) were independent prognostic parameters.
Conclusions:   According to the present series, survival for patients with ≤pT2 does not depend on the lymph node stage. Lymphovascular invasion is an independent parameter of impaired survival and should be determined routinely in cystectomy specimens to identify patients, who may benefit from adjuvant systemic therapy.     

Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia

Background

Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data.

Methods

All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020.

Results

Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020).

Conclusion

The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.     

Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic

Objective To identify symptom clusters, management strategies and survey patient satisfaction in our combined multidisciplinary pelvic floor clinic (PFC). Method Retrospective cohort study, patient satisfaction questionnaire. Sample: Secondary and tertiary referrals with complex pelvic floor disorders. Main outcome measures: symptom clusters and treatment received; patient satisfaction. Results A total of 113 new cases over a 3‐year period. There were two main symptom clusters: (i) obstructed defaecation with rectoceles (n = 55); of these, 23 had abdominal sacrocolpopexy with rectopexy, six had transvaginal rectocele repairs; and (ii) of the 33 with double incontinence, 10 had anal sphincter repairs, five had tension‐free vaginal tapes and two had colposuspensions. Patient satisfaction audit: 73% found the care to be excellent/good, 12% satisfactory and 6% unsatisfactory. Conclusion Combined PFCs led to a more pragmatic approach in treating patients’ symptoms. Combined surgery was undertaken in one‐fourth of patients and is associated with cost savings and a single recuperation period. Overall, patients rated this service very highly.     

Plasma and renal clearances of lactated Ringer's solution in pediatric and adult patients just before anesthesia is induced

Background:  Lactated Ringer's solution is most widely used in children, but little is known about how children who are scheduled for surgery handle a fluid load when compared to adults. This study explores whether a more cautious regimen for the administration of lactated Ringer's is warranted in children awaiting minor surgery when compared to adults.
Methods:  Plasma dilution (based on hemoglobin), urinary excretion, and volume kinetics were used to assess the disposition of an i.v. infusion of 10 ml·kg⁻¹ of lactated Ringer's solution over 20 min in 14 pediatric patients (4 years of age, average body weight 15 kg) and in 14 adult patients scheduled for similar minor pelvic surgery. Experiments were performed after premedication, but before anesthesia was induced.
Results:  Plasma dilution was less pronounced in the pediatric patients ( P  <   0.03) who also had excreted more of the infused fluid within 90 min than the adults (43% vs 18%, P  <   0.03). After correction for body weight, their plasma clearance was 4 times higher ( P  <   0.02) and the renal clearance of lactated Ringer's solution 7 times higher ( P  <   0.001) than those of the adults. The more rapid turnover of fluid in the children might be explained by a shorter period of preoperative fasting (6 vs 10 h) and/or by physiological differences attributable to age.
Conclusion:  The plasma and renal clearances of lactated Ringer's solution were higher in children with a body weight of about 15 kg in comparison with adults. Therefore, children in this age group may receive at least the same amounts of fluid per kilo body weight during preparation for surgery as the amounts recommended for adults.     

Risk of second primary colorectal cancer with particular reference to age at diagnosis

Objective:  Adenocarcinoma of the perineum is unusual. This series of nine patients highlights the challenges of management.
Method:  Six male and three female patients aged 29–85 years presented to a single unit, five were T4 and three were T3 tumours.
Results:  Pain and swelling in the perineum and perianal tissues remote from the anal canal occurred in six patients whilst three patients had chronic perineal fistulae, two of whom had longstanding Crohn's disease. In eight patients a primary adenocarcinoma was identified. One patient with fistulating perineal Crohn's disease had multifocal mucinous adenocarcinoma without evidence of a gastrointestinal primary. Radical multimodality treatment including long course chemo-radiotherapy (CRT) and radical abdominoperineal resection was used in seven patients, four of whom required perineal reconstruction with myocutaneous flaps. Two patients had CRT without surgery (one unresectable and one refused surgery). Negative resection margins were achieved in six of seven patients. All seven patients undergoing resection were well palliated with relief of pain and currently four patients remain free of disease with only one patient developing further perineal disease remote from the surgical resection site.
Conclusion:  Perineal adenocarcinoma may be associated with an occult colorectal primary or chronic fistulae. Lower GI endoscopy and biopsies of non-healing mucous producing fistulae should be undertaken to establish the diagnosis. Radical surgery often achieves local disease control.     

Treatment and outcome of recurrent pelvic chondrosarcoma

Little has been published about the outcome of patients with recurrent chondrosarcoma of the pelvis. The current study is a review of patients with surgically treated locally recurrent pelvic chondrosarcoma at one institution. Twenty-one patients had surgical resection of recurrent pelvic chondrosarcoma between July 1974 and July 1996. There were nine women and 12 men with a mean age of 46 years (range, 24-67 years) at first recurrence. Patients were followed up for a minimum of 3.3 years and median of 12 years from first (index) recurrence or until death. The mean time to index recurrence was 27 months (range, 5-87 months). In three cases (14%), the tumor at index recurrence was a higher grade than the initial lesion. There were six additional tumors that became a higher grade during subsequent recurrences. Fifteen of the 21 patients (71%) had a second local recurrence. Five patients (24%) had distant metastasis. At death or final followup, 11 patients (52%) had no evidence of disease, two patients (10%) are alive with disease, and eight patients (38%) died of their disease. The three patients with high-grade tumors at index recurrence all died of disease. The treatment of recurrent pelvic chondrosarcoma is a challenging problem. Tumor-free margins may require radical surgery, and the best chance of cure is at the time of initial resection. With aggressive surgical intervention, approximately 50% of patients with recurrent pelvic chondrosarcoma can achieve long-term survival.     

Evaluation of a pre-operative staging protocol in the management of colorectal carcinoma

OBJECTIVE: The optimum strategy for pre-operative staging of colorectal carcinoma (CRC) has yet to be defined. A protocol for staging CRC patients was set up in this hospital in 1998. The protocol included complete colonic visualization together with assessment of the liver and lung for potential metastatic disease. Pelvic imaging was required to assess the local spread of rectal tumours. Our aim was to evaluate prospectively this protocol. PATIENTS AND METHODS: Data from all patients diagnosed with primary CRC between January 1999 and December 2002 were prospectively collected and analysed. RESULTS: There were 295 patients; 56 (19%) patients presented as an emergency and were excluded. The study group consisted of 239 patients (206 had elective surgery and 33 had no resectional surgery). In the patients who presented electively; 88% had complete colonic imaging; 87% chest imaging; 90% had liver imaging; 91% of rectal tumours had pelvic imaging. Overall 75% of the elective patients completed the staging protocol. Reasons for incomplete staging were numerous and most were justifiable. Findings which influenced clinical management included alteration in surgical approach (14), lung metastases (7), primary lung cancers (2), definite liver metastases (25), possible liver metastases (8), neo-adjuvant radiotherapy required (27), advanced local disease (9) and other incidental findings (12). CONCLUSION: Our protocol influenced further management decisions in 39% of patients. Better stratification of patient care is possible, with the ultimate aim to avoid unnecessary surgery. However, complete staging is not always possible to perform.     

Differences in multidisciplinary team assessment and treatment between patients with stage IV colon and rectal cancer

Objective  At diagnosis, 14–27% of patients with colorectal cancer (CRC) have distant metastases (stage IV) and a poor prognosis. Today, treatment decisions for CRC patients are often made at multidisciplinary team (MDT) conferences. The aim of this study was to evaluate the effects of development and implementation of MDT assessment and treatment in patients with stage IV colon cancer (CC) and rectal cancer (RC) in a large population.
Method  All 1449 patients who had stage IV CRC at the time of diagnosis and were registered in the regional quality registry of Stockholm from 1995 to 2004 were included. Patients with CC and RC were grouped according to treatment and their characteristics were analysed separately.
Results  In total, 1000 patients with CC and 449 patients with RC had stage IV disease. Of these, 689 (68.9%) CC patients and 352 (78.4%) RC patients were assessed by a MDT and the proportion increased over the study period ( P  < 0.001). Surgery for metastases was undertaken on 39 (3.9%) CC patients and 38 (8.5%) RC patients ( P  < 0.001). CRC patients selected for metastasis surgery had 37% 5-year survival when compared with 2% in patients who were not selected for metastasis surgery ( P  < 0.001).
Conclusion  Patients with CC were less often assessed by a MDT and less often had metastasis surgery than RC patients. The proportion of patients with CC and RC assessed by a MDT increased during the study period, as did the proportion who had surgery for metastases. MDT assessment opens up the opportunity for more aggressive treatment with better outcomes.     

Risk factors for perioperative adverse events in children with myotonic dystrophy

Background:  This study was conducted to identify patient-related, surgical, and anesthetic factors that would help predict adverse events and allow for better planning of perioperative care in children with myotonic dystrophy.
Methods:  This is a retrospective chart review from a large tertiary pediatric hospital. Data were collected on demographics, disease severity, surgical procedure, and anesthetic technique. Perioperative adverse events were recorded.
Results:  Records on 27 patients having 78 anesthetics over a 17.5-year period were reviewed. The overall frequency of postoperative respiratory complications was 10%. Significant risk factors were high muscular impairment rating scale (MIRS) grade ( P  = 0.007), at least 2300 cytosine, thymine, guanine (CTG) repeats on the protein kinase gene of chromosome 19q ( P  = 0.009), a longer duration of surgery (RR = 14.0 for surgery lasting at least 1 h; P  = 0.002), perioperative morphine use (RR = 7.7, 95% CI 2.2–12.8; P  = 0.005), intubation ( P  = 0.02), and the use of muscle relaxant without reversal (RR = 15.5, P  = 0.0002). Using a multivariate risk model, only MIRS grade and the use of muscle relaxant without reversal were shown to be significant independent risk factors (RR = 24.9, P  < 0.0001).
Conclusions:  The MIRS is a statistically significant and clinically useful tool for predicting high perioperative risk. Patients with a high MIRS grade should therefore be considered for postoperative intensive care. The use of muscle relaxant without reversal was also shown to be a significant risk factor. Patients who require morphine infusions postoperatively might also be most safely managed in a high dependency unit.     

Risk of second primary colorectal cancer with particular reference to age at diagnosis

Objective:  Adenocarcinoma of the perineum is unusual. This series of nine patients highlights the challenges of management.
Results:  Six male and three female patients aged 29–85 years presented to a single unit, five were T4 and three were T3 tumours. Pain and swelling in the perineum and perianal tissues remote from the anal canal occurred in six patients whilst three patients had chronic perineal fistulae, two of whom had longstanding Crohn's disease. In eight patients a primary adenocarcinoma was identified. One patient with fistulating perineal Crohn's disease had multifocal mucinous adenocarcinoma without evidence of a gastrointestinal primary. Radical multimodality treatment including long course chemo-radiotherapy (CRT) and radical abdominoperineal resection was used in seven patients, four of whom required perineal reconstruction with myocutaneous flaps. Two patients had CRT without surgery, (one unresectable and one refused surgery). Negative resection margins were achieved in six out of seven patients. All seven patients undergoing resection were well palliated with relief of pain and currently four patients remain free of disease with only one patient developing further perineal disease remote from the surgical resection site.
Conclusion:  Perineal adenocarcinoma may be associated with an occult colorectal primary or chronic fistulae. Lower GI endoscopy and biopsies of nonhealing mucous producing fistulae should be undertaken to establish the diagnosis. Radical surgery often achieves local disease control.     

The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

Purpose: Hemodynamically unstable patients with pelvic fractures still represent a challenge to trauma surgeons and have a very high mortality. This study was designed to explore the effect of the interventions of direct preperitoneal pelvic packing for the hemodynamically unstable pelvic fractures. Methods: This retrospective study enrolled 67 cases of severe pelvic fractures with unstable hemodynamics from October 2011 to December 2019. All patients presented in our emergency center and received preperitoneal pelvic packing were included in this study. The indication was persistent systolic blood pressure 90 mmHg during initial resuscitation and after transfusion of two units of red blood cells. Patients with hemodynamic stability who need no preperitoneal pelvic packing to control bleeding were excluded. Their demographic characteristics, clinical features, laboratory results, therapeutic interventions, adverse events, and prognostic outcomes were collected from digital information system of electronic medical records. Statistics were described as mean ± standard deviation or medium and analyzed using pair sample t-test or Mann-Whitney U-test. Results: The patients’ average age was 41.6 years, ranging from 10 to 88 years. Among them, 45 cases were male (67.2%) and 22 cases were female (32.8%). Significant difference was found regarding the systolic blood pressure (mmHg) in the emergency department (78.4 ± 13.9) and after preperitoneal pelvic packing in the surgery intensive care unit (100.1 ± 17.6) (p < 0.05). Simultaneously, the arterial base deficit (mmol/L) were significantly lower in the surgery intensive care unit (median -6, interquartile range -8 to -2) than in the emergency department (median -10, interquartile range -14 to -8) (p < 0.05).After preperitoneal pelvic packing, 15 patients (22.4%) underwent pelvic angiography for persistent hypotension or suspected ongoing haemorrhage. The overall mortality rate was 29.5% (20 of 67). Conclusions: Preperitoneal pelvic packing, as a useful surgical technique, is less invasive and can be very efficient in early intra-pelvic bleed control.     

Pessary treatment of pelvic relaxation: factors affecting successful fitting and continued use.

OBJECTIVES: The aims of this study were to determine predictors of successful pessary fitting and continued pessary use in patients with pelvic relaxation. DESIGN: Retrospective observational study. SETTING AND SUBJECTS: The medical records of 130 consecutive patients evaluated for pessary treatment of pelvic relaxation by a single specially trained nurse practitioner (CRJ) at Kaiser Foundation Hospital, Harbor City, Calif, between May 1, 1997, and June 30, 2002, were retrospectively reviewed. INSTRUMENTS: Voiding diaries, data collection sheet, and questionnaires. METHODS: The medical records of the 130 patients were retrospectively reviewed, and data were recorded on data collection sheets. Patients using pessaries completed a questionnaire to assess treatment effectiveness. RESULTS: Coexisting stress urinary incontinence and previous prolapse and cystocele/rectocele repairs were each found to be independent predictors of unsuccessful pessary fitting. Fifty percent of successfully fitted patients had discontinued pessary use by 24 months. Current pessary users were more likely to have undergone prior pelvic reconstructive surgery (37% vs 13%, P = .02), less likely to require a space-filling pessary (13% vs 37%, P = .03), and more likely to recommend pessary to their friends or family (87% vs 50%, P = .007) compared to patients who discontinued pessary use. CONCLUSIONS: Prior pelvic reconstructive surgery is associated with an increased risk of unsuccessful pessary fitting; however, those patients who are successfully fitted tend to continue pessary use.     

Preservation of sexual and bladder function after laparoscopic rectal surgery

Background  There have recently been reports of higher levels of bladder and sexual dysfunction in men after laparoscopic rectal surgery when compared with those undergoing open surgery. This has led some surgeons to question the role of the laparoscopic approach to rectal surgery.
Method  This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2406 patients undergoing laparoscopic colorectal surgery. Bladder function, potency and ejaculation were assessed at postoperative clinic visits for men undergoing laparoscopic low or ultra-low anterior resection and abdominoperineal excision of the rectum.
Results  A total of 101 males were identified (median age 62 years: range 20–90 years). Urinary dysfunction was reported by six (6%) patients. Six (6%) patients had sexual dysfunction, manifesting as retrograde ejaculation in four patients and erectile dysfunction in a further two patients.
Conclusions  The low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced, dedicated laparoscopic colorectal surgeons. Laparoscopic restorative surgery for rectal cancer has been performed here only since 2001 after considerable experience accrued in operating on benign rectal disease and colon cancer. Studies from elsewhere reporting poorer functional outcomes have probably included a significant number of patients on the surgeons'learning curve'.     

Evacuation proctography – should it be part of the assessment of all patients with faecal incontinence?

Introduction:  Evacuation Proctography (EP) is rarely incorporated into the assessment of patients with faecal incontinence (FI). Continence-restoring surgery (e.g. sphincteroplasty, ESGN) may result in the worsening or unmasking of a pre-existing rectal evacuatory disorder (RED), or precipitate a new-onset RED. This study compared the incidence of RED, diagnosed on EP, between patients with FI, with or without symptoms of RED.
Method:  A retrospective study of 250 patients with FI (mean age 53 years; range 21–83 years, F  = 213), +/­ symptoms of RED, referred for comprehensive physiological investigation. Proctographic diagnoses were classified as: normal; functional i.e. no clear anatomical cause (e.g. pelvic floor dyssynergia); mechanical (e.g. rectocoele, intussusception; deemed to obstruct evacuation) or mechanical and functional .
Results:  Seventy-three patients (29%) had isolated FI; the remaining 177 (71%) had FI combined with symptoms of RED.
 

     

17.

Perioperative cardiac arrests in children at a university teaching hospital of a developing country over 15 years     

ALIYA AHMED FFARCSI    MOHAMMAD ALI FCPS    MUEENULLAH KHAN FCPS    FAUZIA KHAN FRCA 《Paediatric anaesthesia》2009,19(6):581-586

Objective/Aim:  To study the incidence, causes, and outcome of perioperative cardiac arrests in children at a university teaching hospital with an aim of improving quality of care.
Background:  Analysis of anesthesia-related complications is routinely performed by most anesthesia departments to make prevention strategies.
Methods:  All perioperative cardiac arrests in children up to 18 years from induction of anesthesia to postanesthesia care unit discharge or ICU admission during noncardiac surgery from January 1992 to December 2006 were analyzed. Outcome variable was noted as survival to discharge. Anesthesia-related cardiac arrests were identified and their causes analyzed.
Results:  Ten cardiac arrests occurred among 20216 patients. Overall incidence was 4.95 per 10000 (95% CI: 1.88–8.01). Six (6.53/10000) were females. Seven (19.44/10000) patients belonged to the classification III–IV of ASA physical status, eight (18.28/10000) were below 1 year, and two (1.26/10000) above 1 year. Three patients (6.53/10000) were undergoing emergency surgery. Anesthesia was primarily responsible in four cases. The causes of anesthesia-related arrests were medication-related (two), airway-related (one), and under-replacement of fluids (one). Seven patients died during the arrest and three were discharged home. The event was considered avoidable in seven (70%) cases.
Conclusion:  Perioperative cardiac arrests were higher in patients with poor physical status, in those under 1 year of age, and in female patients. Anesthesia-related cardiac arrests were mainly due to medication- or airway-related causes. The majority of arrests were avoidable indicating the importance of prevention strategies.     

18.

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India     

J. Nath  C. Wigley  M. R. B. Keighley†  B. Perakath 《Colorectal disease》2009,11(5):475-479

Objective  Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts.
Method  All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database.
Results  One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% ( P  < 0.001)) and low rectal tumours (63.0% vs 50.0%) ( P  = 0.043), but were equally likely to undergo curative surgery compared to the older group ( P  = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0–2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) ( P  = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) ( P  = 0.014).
Conclusion  The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.     

19.

Results of treatment of renal calculi with lower-pole fluoroscopically guided percutaneous nephrolithotomy     

Koji Nishizawa  Hitoshi Yamada  Yu Miyazaki  Go Kobori  Yoshito Higashi 《International journal of urology》2008,15(5):399-402

Objective:   To prospectively assess the clinical efficacy and safety of lower-pole fluoroscopically guided percutaneous nephrolithotomy (PNL).
Methods:   A total of 90 renal units in 87 patients underwent lower-pole fluoroscopically guided PNL for renal calculi. The average patient age was 56.0 years. Staghorn calculi were present in 41 renal units. There were 22 were upper pole, 54 middle pole, 76 lower pole, 70 pelvic and 18 ureteropelvic junction calculi. Patients without significant residual fragments greater than 3mm on postoperative day 2 were defined as primarily successful. Significant residual fragments were treated with shock wave lithotripsy (SWL) every other day from postoperative day 3.
Results:   Mean operative time was 129.5 min (SD, 49.0). Blood transfusion was required in four patients. Septic shock developed in three patients. Sixty-three percent of the patients (57 of 90 procedures) were primarily successful after PNL: 83.7% of non-staghorn patients (41 of 49 procedures) and 39.0% of staghorn patients (16 of 41 procedures). Of the 33 patients with significant residual fragments, 13 staghorn and six non-staghorn patients had residual fragments in their middle calyces. Of the preoperative variables, staghorn calculus and calculus in the middle calyx were significant predictors of significant residual fragments after PNL. After adjunctive SWL, the overall success rate was 94.5%.
Conclusions:   Our study suggests that lower-pole fluoroscopically guided PNL is a safe and effective therapy for patients with staghorn or non-staghorn calculi. In patients with staghorn calculi or calculi in the middle calyx, adjunctive treatment is sometimes required to treat significant residual fragments.     

20.

Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse     

Kumiko Kato  Shoji Suzuki  Shigeki Yamamoto  Kenichi Furuhashi  Koichi Suzuki  Tatsuro Murase  Momokazu Gotoh 《International journal of urology》2009,16(3):314-317

Objectives:   To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP).
Methods:   Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series.
Results:   Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain.
Conclusions:   Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.     

Perioperative cardiac arrests in children at a university teaching hospital of a developing country over 15 years

Objective/Aim:  To study the incidence, causes, and outcome of perioperative cardiac arrests in children at a university teaching hospital with an aim of improving quality of care.
Background:  Analysis of anesthesia-related complications is routinely performed by most anesthesia departments to make prevention strategies.
Methods:  All perioperative cardiac arrests in children up to 18 years from induction of anesthesia to postanesthesia care unit discharge or ICU admission during noncardiac surgery from January 1992 to December 2006 were analyzed. Outcome variable was noted as survival to discharge. Anesthesia-related cardiac arrests were identified and their causes analyzed.
Results:  Ten cardiac arrests occurred among 20216 patients. Overall incidence was 4.95 per 10000 (95% CI: 1.88–8.01). Six (6.53/10000) were females. Seven (19.44/10000) patients belonged to the classification III–IV of ASA physical status, eight (18.28/10000) were below 1 year, and two (1.26/10000) above 1 year. Three patients (6.53/10000) were undergoing emergency surgery. Anesthesia was primarily responsible in four cases. The causes of anesthesia-related arrests were medication-related (two), airway-related (one), and under-replacement of fluids (one). Seven patients died during the arrest and three were discharged home. The event was considered avoidable in seven (70%) cases.
Conclusion:  Perioperative cardiac arrests were higher in patients with poor physical status, in those under 1 year of age, and in female patients. Anesthesia-related cardiac arrests were mainly due to medication- or airway-related causes. The majority of arrests were avoidable indicating the importance of prevention strategies.     

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India

Objective  Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts.
Method  All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database.
Results  One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% ( P  < 0.001)) and low rectal tumours (63.0% vs 50.0%) ( P  = 0.043), but were equally likely to undergo curative surgery compared to the older group ( P  = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0–2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) ( P  = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) ( P  = 0.014).
Conclusion  The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.     

Results of treatment of renal calculi with lower-pole fluoroscopically guided percutaneous nephrolithotomy

Objective:   To prospectively assess the clinical efficacy and safety of lower-pole fluoroscopically guided percutaneous nephrolithotomy (PNL).
Methods:   A total of 90 renal units in 87 patients underwent lower-pole fluoroscopically guided PNL for renal calculi. The average patient age was 56.0 years. Staghorn calculi were present in 41 renal units. There were 22 were upper pole, 54 middle pole, 76 lower pole, 70 pelvic and 18 ureteropelvic junction calculi. Patients without significant residual fragments greater than 3mm on postoperative day 2 were defined as primarily successful. Significant residual fragments were treated with shock wave lithotripsy (SWL) every other day from postoperative day 3.
Results:   Mean operative time was 129.5 min (SD, 49.0). Blood transfusion was required in four patients. Septic shock developed in three patients. Sixty-three percent of the patients (57 of 90 procedures) were primarily successful after PNL: 83.7% of non-staghorn patients (41 of 49 procedures) and 39.0% of staghorn patients (16 of 41 procedures). Of the 33 patients with significant residual fragments, 13 staghorn and six non-staghorn patients had residual fragments in their middle calyces. Of the preoperative variables, staghorn calculus and calculus in the middle calyx were significant predictors of significant residual fragments after PNL. After adjunctive SWL, the overall success rate was 94.5%.
Conclusions:   Our study suggests that lower-pole fluoroscopically guided PNL is a safe and effective therapy for patients with staghorn or non-staghorn calculi. In patients with staghorn calculi or calculi in the middle calyx, adjunctive treatment is sometimes required to treat significant residual fragments.     

Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse

Objectives:   To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP).
Methods:   Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series.
Results:   Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain.
Conclusions:   Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.