Adequate lymphadenectomy for colorectal cancer: a comparative analysis between open and laparoscopic surgery

Background

In the surgical treatment of colorectal cancer, a lymphadenectomy is considered adequate when at least 12 lymph nodes are removed.

Aim

To evaluate whether videolaparoscopic surgery positively affects the rates of adequate lymphadenectomy.

Methods

An observational study was conducted with patients undergoing either open or videolaparoscopic surgery for colorectal cancer between 2008 and 2013. The following variables were collected: gender, age, tumor site, histology, degree of differentiation, tumor stage, number of lymph nodes removed, and number of lymph nodes affected by the disease.

Results

A total of 62 patients with colorectal cancer were included; 42 (67.7%) received open surgery, and 20 (32.3%) laparoscopic surgery. Regarding lymphadenectomy, a mean of 13 lymph nodes (95% CI: 10-16) were removed in the group that received open surgery, while 19 lymph nodes were removed (95% CI: 14-24) in the laparoscopic surgery group (p=0.021). Adequate lymphadenectomy (removal of at least 12 lymph nodes) was achieved in 58.1% of the total cases, in 50.0% of the patients who received open surgery, and in 75% of those who received laparoscopic surgery. Non-elderly patients and those with an advanced disease stage were more likely to receive an adequate lymphadenectomy (p=0.004 and p=0.035, respectively).

Conclusion

Disease stage and patient age were the factors that had the greatest influence on achieving an adequate lymphadenectomy. The type of surgery did not affect the number of lymph nodes removed.     

Enhanced recovery in major colorectal surgery: Safety and efficacy in an unselected surgical population at a UK district general hospital

Background

Enhanced Recovery Programmes (ERPs) have been shown to benefit recovery following major surgery in selected centres and patient groups, but their wider applicability requires continued evaluation. The aims of this study were to assess the outcomes of the first 400 consecutive, non-selected patients, undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes.

Methods

Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospectively on a database. Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective, pre-ERP group; and according to patient risk factors and operative approaches.

Results

Median length of stays (LOS) reduced from 9 days (IQR 7–11) to 6 days (IQR 5–10) after introduction of the ERP (p < 0.001). No statistically significant differences in LOS were observed between elderly (≥80 years) and younger patients or between different BMI groups. American Society of Anesthesiologists (ASA) grade 3 patients demonstrated significantly longer median LOS than those with ASA grades 1 and 2. Patients undergoing laparoscopic surgery had median LOS of 6 days (IQR 4–8) compared to 7 days (IQR 5–10) for open procedures (p < 0.001). No differences in morbidity or mortality were observed between the groups.

Conclusions

Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS. The ERP was safe and effective when applied to all our study patients independent of age and BMI. Despite LOS being longer in ASA grade 3 patients, application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality. Laparoscopic surgery resulted in additional modest reductions in LOS compared to open surgery within the ERP.     

Consenting for pelvic nerve injury in colorectal surgery: need to address age and gender bias

INTRODUCTION

Pelvic nerve injury is a recognised complication following pelvic dissection in colorectal surgery. It can lead to urinary and sexual dysfunction in men and women, which varies from 5-40% depending on the surgery and the underlying pathology. Sexual dysfunction can manifest as erectile dysfunction in men and as dyspareunia and failure to achieve sexual arousal/orgasm in women. The aim of this study was to evaluate consent for these complications prior to surgery.

PATIENTS AND METHODS

We carried out a retrospective audit on patients who had undergone elective colorectal surgery involving pelvic dissection over a 2-year period (June 2006 to June 2008) at University Hospital of North Staffordshire. We reviewed the consent forms and medical records of these patients, specifically looking for documentation of pelvic nerve injury, sexual dysfunction or erectile dysfunction prior to surgery. Only patients who had documented pelvic dissection in their operative notes were included in the audit, and those who were deemed unable to consent were excluded.

RESULTS

Medical records of 118 patients were reviewed. Of this cohort, 31% were women (n = 37). Malignancy was the indication for surgery in 79% of women and 88% of men. Consent for the procedure was obtained by a consultant in 73% (n = 86) of patients and by a middle-grade surgeon in the remaining 27% (n = 32). Only two women were consented for pelvic nerve injury whilst this number was 41 for men (5% vs 51%). Patients younger than 50 years were more consistently informed of the risks (50%) compared to the over 50-year-olds (34%). Only eight patients (males 6, females 2) were consented for urinary dysfunction.

CONCLUSIONS

The risk of pelvic nerve injury is not frequently stated, which is more common in women and the elderly. Overall, only 36% of patients were consented for pelvic nerve injury, while only 5% of women were consented. Is this professional discretion, or evidence that surgeons are not being assiduous enough when obtaining consent, which may leave them vulnerable to medicolegal claims? Introduction of procedure-specific consent forms would be a method to address this issue.     

Age at death of patients with colorectal cancer and the effect of lead‐time bias on survival in elective vs emergency surgery

Aim Colorectal cancer survival depends on stage at presentation, and current strategies aim for improvements through early detection. Previous studies have demonstrated improved survival from diagnosis but not increased life expectancy. While lead‐time bias may account for variations in known prognostic indicators and also influence screening programmes, only age at death provides a true representation of the effectiveness of an intervention. We aimed to compare age at death for patients with colorectal cancer presenting on an emergency or elective basis. Method Patients presenting with colorectal cancer (2000–2006) were entered into a prospective database (analysis 1 December 2008). Fields included age at death, emergency/elective presentation, palliative/curative intent and disease stage. Results One thousand six hundred and fifty patients (922 men) were identified. Elective patients presented younger than emergency patients (67.9 vs 70.6 years; P < 0.005). Dukes B patients presented older than Dukes D (P = 0.02). Mortality was 41% at time of analysis; no difference was seen in mean age at death between emergency and elective presentation (72.8 vs 72.0 years; P = 0.379) or palliative and curative intent (72.0 vs 72.5 years; P = 0.604). Conclusion Colorectal cancer is common in a population where actuarial life expectancy is limited. Current colorectal cancer early detection strategies may improve cancer‐specific survival by increasing lead‐time bias but do not influence overall life expectancy.     

广州地区某三甲医院普通外科2017年多重耐药情况分析与应对

目的探讨广州地区某三甲医院普通外科多重耐药现状,分析发生多重耐药的原因,为制定应对策略提供参考。 方法统计广州市花都区人民医院普通外科2017年目标监测多重耐药菌的例数及其构成比,分析多重耐药患者的疾病构成及年龄分布,寻找出现多重耐药的原因。 结果2017年普通外科共发生434例多重耐药,目标监测多重耐药菌主要是大肠埃希菌,占73.50%,且对头孢类抗菌药物和喹诺酮类抗菌药物的耐药比例较高。病种分布中阑尾炎患者约占61.52%（267/434）,且以急性阑尾炎患者为主（125例,46.82%）。年龄集中分布于青、中年患者,65岁以下的患者占88.02%（382/434）。403例（92.86%）为非外伤性疾病,91例（20.97%）存在合并症,307例（70.74%）未更改经验性抗感染治疗方案。 结论普通外科多重耐药渐趋明显,其中大肠埃希菌多重耐药率高于全院甚至全国的耐药率,且多重耐药患者的病种和年龄分布异常,其原因可能与医疗机构以及患者不合理使用抗菌药物导致细菌变异有关,同时不排除为本地区畜牧养殖业滥用抗菌药物的原因。     

Patients 35 years old or younger with operable breast cancer are more at risk for relapse and survival: a retrospective matched case-control study

It has long been suggested that younger women with breast cancer have less favorable prognostic factors and poorer outcomes. Our main objectives were to determine whether poor prognosis among young women was independent of other common clinicopathologic parameters. We retrospectively analyzed 551 young patients (≤35 years, Group I) and 551 older patients (36–50 years, Group II), matched for year of diagnosis, family history of breast cancer, pathologic stage, hormone receptor expression and application of adjuvant therapy. Patients in Group I had significantly shorter disease-free survival (DFS) than Group II (median 23.2 months vs. 28.4 months, P = 0.024). Five-year DFS rate(63.7% vs. 74.7%, P < 0.001) and overall survival (OS) rate (79.5% vs. 85.6%, P = 0.024) in Group I was inferior to those in Group II. Multivariate analysis showed that young age was a significantly negative predictor for DFS and OS. Our study thus shows that age (≤35 y/o) is an independent risk factor for prognosis in operable breast cancer.     

Weight-bearing bones are more sensitive to physical exercise in boys than in girls during pre- and early puberty: a cross-sectional study

Summary  We carried out a cross-section study of the sex-specific relationship between bone mineral content and physical activity at sites with different loading in pre- and early pubertal girls and boys. There was significant sensitivity of bone mineral content of the hip to physical exercise in boys, but not in girls. Background  Since little is known whether there are sex differences in sensitivity of bone to loading, we investigated sex differences in the cross-sectional association between measures of physical activity (PA) and bone mass and size in pre- and early pubertal children of both sexes. Methods  We measured bone mineral content/density (BMC/BMD) and fat-free mass (FFM) in 269 6- to 13-year-old children from randomly selected schools by dual-energy X-ray absorptiometry. Physical activity (PA) was measured by accelerometers and lower extremity strength by a jump-and-reach test. Results  Boys (n = 128) had higher hip and total body BMC and BMD, higher FFM, higher muscle strength and were more physically active than girls (n = 141). Total hip BMC was positively associated with time spent in total and vigorous PA in boys (r = 0.20–0.33, p < 0.01), but not in girls (r = 0.02–0.04, p = ns), even after adjusting for FFM and strength. While boys and girls in the lowest tertile of vigorous PA (22 min/day) did not differ in hip BMC (15.62 vs 15.52 g), boys in the highest tertile (72 min/day) had significantly higher values than the corresponding girls (16.84 vs 15.71 g, p < 0.05). Conclusions  Sex differences in BMC during pre- and early puberty may be related to a different sensitivity of bone to physical loading, irrespective of muscle mass.     

General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update

Background

Complications from general anesthesia for cesarean delivery are a leading cause of anesthesia-related mortality. As a consequence, the overall use of general anesthesia in this setting is becoming less common. The impact and implications of this trend are considered in relation to a similar study performed at our institution 10 years ago.

Methods

The hospital database for all cesarean deliveries performed during six calendar years (January 1, 2000 through December 31, 2005) was reviewed. The medical records of all parturients who received general anesthesia were examined to collect personal details and data pertinent to the indications for cesarean delivery and general anesthesia, mode of airway management and associated anesthetic complications.

Results

Cesarean deliveries accounted for 23.65% to 31.51% of an annual total ranging from 8543 to 10091 deliveries. The percentage of cases performed under general anesthesia ranged from 0.5% to 1%. A perceived lack of time for neuraxial anesthesia accounted for more than half of the general anesthesia cases each year, with maternal factors accounting for 11.1% to 42.9%. Failures of neuraxial techniques accounted for less than 4% of the general anesthesia cases. There was only one case of difficult intubation and no anesthesia-related mortality was recorded.

Conclusion

The use of general anesthesia for cesarean delivery is low and declining. These trends may reflect the early and increasing use of neuraxial techniques, particularly in parturients with co-existing morbidities. A significant reduction in exposure of trainees to obstetric general anesthesia has been observed.     

Synoviocytes are more sensitive than cartilage to the effects of minocycline and doxycycline on IL‐1α and MMP‐13‐induced catabolic gene responses

The objective of this study was to determine the primary articular tissue target of doxycycline and minocycline. Synoviocytes—cartilage cocultures (n = 4) were treated with MMP‐13 (25 ng/mL medium) or IL‐1 (1.0 ng/mL medium) for 24 h. Doxycycline (4.3, 0.43, 0.043 µM) or minocycline (10, 1.0 or 0.1 µM) were then added and cultures were continued for 96 h. Cartilage and media were analyzed for GAG content. Quantitative PCR was used to measure cartilage MMP‐3, MMP‐13, aggrecan, COL2A1, ADAMTS‐4, and ADAMTS‐5 expression, and synoviocyte MMP‐3, MMP‐13, ADAMTS‐4, and ADMATS‐5 expression. Total and active MMP‐3, MMP‐13, and ADAMTS 4/5 enzymes were measured in culture medium. All concentrations of doxycycline and minocycline diminished GAG accumulation in the media. All concentrations of minocycline, but only the highest concentration of doxycycline decreased MMP‐3 and MMP‐13 expression in synoviocytes but not cartilage, and basal ADAMTS‐5 mRNA levels in both synoviocytes and cartilage. Only minocycline decreased active MMP‐13 protein in synoviocytes. In summary, the protective effects of tetracycline compounds are more pronounced in synoviocytes than cartilage, and following minocycline compared to doxycycline. Studies to determine the molecular mechanism of action of the tetracyclines in synoviocytes might lead to the design of targeted therapeutics for the treatment of OA or RA. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 28:522–528, 2010     

The introduction of an emergency safety protocol coupled with simulation training in robotic surgery,has enabled a more cohesive and efficient response to emergencies

With the increasing popularity of robotic surgery, arise a unique set of challenges. In-order to minimise the risk and optimise patient safety, teams need to anticipate these, plan and train to improve familiarity with the nuances of robotic surgery. Human factors and simulation training (ST) are now an integral part of surgery and we have extended these principles to our robotic practice. From our experience with emergencies and a thorough debrief, we have realised the importance of an emergency safety protocol (ESP) for the undocking of the robot, and how training with the correct systems in place optimises our non-technical skills and improves our efficiency. This protocol is used across all robotic specialties allowing for clear communication, situational awareness and role clarity, thereby reducing errors in a high-pressured environment. We aim to share our protocol, highlight the importance of ST and show that coupling of the ESP with ST, including addressing a disrupted power supply and how to avoid the resulting loss of image capture, is where our paper contributes to the current literature. There is a paucity in the literature regarding emergency undocking, and also techniques for avoiding power interruptions, for which we utilise the Uninterruptible Power Supply (UPS) system. By sharing experiences and systems used, we create an opportunity that will result in a culture of shared learning in the robotic community, thereby encouraging other robotic teams to review their protocols and training practices and adapt as necessary.     

Postoperative systems models more accurately predict risk of significant disease progression than standard risk groups and a 10-year postoperative nomogram: potential impact on the receipt of adjuvant therapy after surgery

Study Type – Prognostic (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Physicians are becoming increasingly aware of the need to better understand adverse pathology (e.g. margin positive or extracapsular extension) post‐surgery. Systems models provide the necessary risk discriminatory tools to guide patient monitoring and decision‐making.

OBJECTIVE

• ? To compare the performance of a systems‐based risk assessment tool with standard defined risk groups and the 10‐year postoperative nomogram for predicting disease progression, including biochemical relapse and clinical (systemic) failure.

PATIENTS AND METHODS

• ? Clinical variables, biometric profiles and outcome results from a training cohort comprising 373 patients in a published postoperative systems‐based prognostic model were obtained.
• ? Patients were stratified according to D'Amico standard risk groups, Kattan 10‐year postoperative nomogram and prognostic scores from the postoperative tissue model.
• ? The association of pathological variables and calculated risk groups with biochemical recurrence and clinical (systemic) failure was assessed using the concordance index (C‐index) and hazard ratio (HR).

RESULTS

• ? Systems‐based post‐prostatectomy models to predict significant disease progression (post‐treatment clinical failure) were more accurate than the D'Amico defined risk groups and the Kattan 10‐year postoperative nomogram (systems model: C‐index, 0.84; HR, 17.46; P < 0.001 vs D'Amico: C‐index, 0.73; HR, 11; P= 0.001; 10‐year nomogram: C‐index, 0.79; HR, 5.06; P < 0.001).
• ? The systems models were also more accurate than standard risk groups for predicting prostate‐specific antigen recurrence (systems model: C‐index, 0.76; HR, 8.94; P < 0.001 vs D'Amico C‐ index, 0.70; HR, 4.67; P < 0.001) and showed incremental improvement over the 10‐year postoperative nomogram (C‐index, 0.75; HR, 5.83; P < 0.001).
• ? The postoperative tissue model provided additional risk discrimination over surgical margin status and extracapsular extension for predicting disease outcome, and was most significant for the clinical (systemic) failure endpoint (surgical margin: C‐index, 0.58; HR, 1.57; P= 0.2; extracapsular extension: C‐index, 0.62; HR, 2.06; P= 0.04).

CONCLUSIONS

• ? Risk assessment models that incorporate characteristics from the patient's own tumour specimen are more accurate than clinical‐only nomograms for predicting significant disease outcome.
• ? Systems‐based tools should provide useful information concerning the appropriate receipt of adjuvant therapy in the post‐surgical setting.

     

Quality of rectal cancer surgery and its relationship to surgeon and hospital caseload: a population‐based study

Aim A population‐based audit of all rectal cancers diagnosed in Ireland in 2007 has shown an inconsistent relationship between surgeon and hospital caseload and a range of quality measures. Better outcome for rectal cancer has been associated with increasing surgeon and hospital caseload, but there is less evidence of how this may relate to quality of care. Our aim was to examine how measures of quality in rectal cancer surgery related to surgeon and hospital workload and to outcome. Method All colorectal surgeons in Ireland participated in an audit of rectal cancer based on an evidence‐based instrument. Data were extracted from medical records by trained coders. Generalized linear mixed models were used to determine the relationship between surgeon or hospital caseload and measures of quality of care. Results Five hundred and eighty‐one (95%) of the 614 rectal cancers diagnosed in Ireland in 2007 were audited; 49 hospitals and 86 surgeons participated. Ten (28%) hospitals treated fewer than five cases and seven fewer than three. A positive relationship between caseload and quality was seen for a few measures, more frequently for hospital than surgeon caseload. The relationship between caseload and quality of care was inconsistent, suggesting these measures do not represent a single dimension of quality. One‐year survival was negatively associated with hospital caseload. There was no statistically significant relationship between survival and measures of quality of care. Discussion Quality of care was inconsistently influenced by surgeon and hospital caseload. Caseload may affect only one aspect of surgical management, such as the quality of preoperative workup, and is not necessarily related to the quality of other hospital care. Simple measures of outcome, such as survival, cannot represent the complexity of this relationship.