Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care

Aim The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery. Method Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re‐admission and re‐operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care. Results SSIs were identified in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re‐admission was needed in one LS patient and in 52% OS patients. No LS patient needed re‐operation compared with 12% of OS patients. HHC ($162/dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107/day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients. Conclusion Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients.     

Six-year prospective analysis of the rectal bleeding clinic at the Queen Elizabeth Hospital, Adelaide, South Australia

BACKGROUND: One-stop rectal bleeding clinics (RBC) are designed to diagnose and treat colorectal diseases that present with rectal bleeding. The Queen Elizabeth Hospital RBC is an open access clinic and is unique in South Australia. It offers flexible sigmoidoscopy and facilities for treating common anorectal conditions. METHODS: Data of all patients presenting to the RBC were prospectively recorded into a database. Data were collected on the patient details, presentation, medical history, physical examination, treatment and intended follow-up. RESULTS: A total of 1539 cases was seen in the clinic between March 2000 and February 2006. Flexible sigmoidoscopy was carried out in 1145 cases (75.03%). Banding or injection of haemorrhoids was carried out in 383 cases. A total of 590 patients was referred for colonoscopy and of these, 27 were diagnosed with colorectal adenocarcinoma or squamous cell cancer of the anus. Most of these patients were more than 50 years old (26 of 27; 96.30%) and had associated symptoms, such as weight loss or altered bowel habit with their rectal bleeding (23 of 27; 85.19%). CONCLUSION: Rectal bleeding clinics can facilitate early diagnosis of colorectal malignancy and can also provide a 'one-stop shop' for treating benign anorectal conditions.     

The influence of a colorectal service on the outcome of patients with colorectal cancer

Objective To perform a prospective audit of outcomes and survival of all patients presenting to a colorectal service with colorectal cancer, and to compare these results with an historical control group. Patients and methods At a community based teaching hospital, a prospective audit of outcomes and survival of patients with colorectal cancer was compared with a historical control. The study included all patients referred to a colorectal service with colorectal cancer from 1996 to 2000 (5‐year period). The control group was a retrospective review of patients presenting to the same hospital with colorectal cancer from 1989 to 1994 (6‐year period). A Kaplan‐Meier survival analysis compared the overall survival (all‐cause mortality) between the two groups. Results When comparing the study periods 1989–95 (n = 477) to 1996–2000 (n = 323), there has been a significant reduction in postoperative stay (16.2 vs 8.0 days, P < 0.05), and a reduction in postoperative mortality (4.5%vs 2.7%, n.s.). There was a significant increase in the overall 2 years survival for patients with colorectal cancer (62% to 71%, P < 0.01). There was also a significant increase in the overall 2 years survival of patients with rectal cancer (66% to 74%, P < 0.01), patients with ACPS C colon cancers (64% to 83%, P < 0.05), and ACPS C rectal cancers (74% to 85%, P < 0.01). Conclusions There have been significant gains in the survival of patients presenting to a community based teaching hospital with colorectal cancer. These improvements have been most notable in patients with nodal metastases at the time of diagnosis.     

Evolution of the two-week rule pathway – direct access colonoscopy vs outpatient appointments: one year''s experience and patient satisfaction survey

Abstract Objectives The aim of this study was to compare the effectiveness of Direct access colonoscopy (DAC) vs outpatient appointments for two-week rule colorectal cancer referrals and to evaluate the satisfaction of patients referred through these routes. Patients and methods Data were collected prospectively from January 2003 to December 2003 on patients who were referred for DAC or outpatient appointments at the discretion of the referring General practitioner via the Lower GI two-week rule pathway. A postal questionnaire was used to survey patient satisfaction. Results Six hundred and thirty-nine patients were referred via the two-week rule pathway; 188 patients underwent colonoscopy at their initial hospital visit and 19 (10.1%) colorectal cancers were diagnosed; 442 patients had an outpatient appointment and 32 (7.2%) colorectal cancers were identified. There were 7 (1%) inappropriate referrals and 2 patients refused investigations. All outcome parameters measured were reduced for patients referred directly for colonoscopy including time to definitive investigations (Median 9 vs 52 days P < 0.0001), time to histological diagnosis (Median 14 vs 42 days P < 0.0001) and time to treatment (Median 55 vs 75 days P < 0.0483). One hundred and seventy patients were surveyed by the postal questionnaire of whom 127 (75%) responded. Ninety-eight percent of patients were satisfied with the service provided. Four (6.6%) of 60 patients who had undergone direct access colonoscopy expressed a desire to be seen at the outpatient department initially. Conclusions Direct access colonoscopy results in significantly reduced times to histological diagnosis and definitive treatment in patients with colorectal cancer. Patients can be directly admitted for investigations bypassing the outpatient clinic without affecting patient satisfaction.     

The outcome of patients on the cholecystectomy waiting list in Western Australia 1999-2005

Background: Surgeons are noticing increasing numbers of cholecystectomy waiting list patients presenting with complications of their gallstones. In this study, we analysed the outcome of these to ascertain natural history and outcome. Methods: Data for 5298 waiting list patients in Western Australia, from 1999 to 2006, were analysed. Negative binomial regression was used to analyse waiting times data with Waitlist Year, Urgency Category and Aboriginality, after adjusting for Gender, Location and Age at Cholecystectomy. Results: The overall median waiting time for surgery was 40 days (interquartile range (IQR) = 15–103). The median waiting times for Urgent, Semi‐Urgent, and Routine categories were 21 (IQR = 8–63), 44 (IQR = 20–97) and 50 (IQR = 17–131) days, respectively. While waiting for surgery, 240 (5%) patients had gallstone‐related admissions. Eighty (33.3%) patients had previous gallstone‐related admissions prior to their enrolment on the waiting list. Analysis of the crude odds ratio showed that the probability of readmission during wait for surgery was three times more, when the surgery was not performed within the recommended time. Aboriginal and Torres Strait Islanders wait 1.77 times longer than non aboriginals (P < 0.001) and waiting time decreased with more recent calendar years. (P= 0.001) Patients in the metropolitan hospitals waited twice as long compared with the regional hospitals (P < 0.001). Conclusion: Approximately 5% of patients on the waiting list for an elective cholecystectomy were readmitted to the hospital for gallstone‐related problems. Proper categorization of patients and definitive surgical treatment of acute gallbladder disease at index presentation might decrease this readmission rate. More effort needs to be made to ensure equity of access for gallstone patients.     

Iron deficiency anaemia and delayed diagnosis of colorectal cancer: a retrospective cohort study

Aim The extent to which different referral pathways following a primary care diagnosis of iron deficiency anaemia (IDA) are associated with delay in diagnosis of colorectal cancer (CRC) was determined. Method Eligible patients aged 40 or more years, with IDA diagnosed in primary care, and a subsequent diagnosis of CRC, were studied retrospectively. Referral pathways were identified using the specialty of first recorded GP referral following IDA diagnosis. Differences in time to diagnosis of CRC were assessed by referral specialty. Differences in the proportion of cases referred before and after the re‐issue of the NICE urgent referral guidelines for suspected lower gastrointestinal (GI) cancer were also assessed. Results Of 628 882 eligible patients, 3.1% (n = 19 349) were diagnosed with IDA during the study period; 3.0% (n = 578) were subsequently diagnosed with CRC. Two hundred and fifty‐nine (44.8%) patients had no recorded referral or a referral unrelated to anaemia or the GI tract. Only 35% (n = 201) of patients were referred to a relevant specialty. Median time to CRC diagnosis ranged from 2.5 months (referral to a relevant surgical specialty) to 31.9 months (haematology). Time to diagnosis was longer in patients referred to a medical compared with a relevant surgical specialty (P = 0.024). There was no significant difference in time to CRC diagnosis before and after the NICE guidelines were re‐issued in 2005. Conclusion Significant differences exist between referral specialties in time to CRC diagnosis following a primary care diagnosis of IDA. Despite NICE referral recommendations, a significant proportion of patients are still not managed within recommended care pathways to CRC diagnosis.     

Does experience with laparoscopic colorectal surgery influence intraoperative outcomes?

Background  This study aimed to define the management and risk factors for intraoperative complications (IOC) and conversion in laparoscopic colorectal surgery, and to assess whether surgeon experience influences intraoperative outcomes. Methods  Consecutive patients undergoing laparoscopic colorectal procedures from 1991 to 2005 were analyzed from a longitudinal prospectively collected database. All patients referred to the four surgeons involved in this study were offered a minimally invasive approach. Patient characteristics, perioperative variables, and surgeon experience data were analyzed and compared. Results  A total of 991 consecutive laparoscopic colorectal procedures were studied. The majority of operations were performed for malignant disease (n = 526, 53%), and most frequently consisted of segmental colonic resections (n = 718, 72%). A total of 85 patients (8.6%) had an IOC. Patients experiencing an IOC had a significantly higher median body weight (75 versus 68 kg, p = 0.0047) and had a higher proportion of previous abdominal surgery (31% versus 20%, p = 0.029). Only 39% of patients suffering an IOC required conversion to open surgery. A total of 126 (13%) cases were converted to open surgery. On multivariable analysis, previous abdominal surgery [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.39–8.35, p = 0.0076] was independently associated with having an IOC and a conversion to open within the same procedure. With increasing experience, individual surgeons were found to operate on heavier patients (p = 0.025), and on patients who had a higher rate of previous intra-abdominal surgery (p < 0.0001). Despite these risk factors, the early and late experience demonstrated no significant difference in terms of IOCs (p = 0.54) and conversion to open surgery (p = 0.40). Conclusions  The majority of IOCs can be managed laparoscopically. With increasing experience surgeons can perform laparoscopic colorectal surgery on a patient population with a greater proportion of previous abdominal surgery and a higher mean body weight without adversely affecting their rates of intraoperative complications or conversion. Oral presentation at the Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons, April 12th, 2008, Philadelphia, PA.     

The impact of national guidelines on the waiting list for colonoscopy: a quantitative clinical audit

Objective To assess the compliance of the surveillance colonoscopy waiting list with ACPGBI/BSG guidelines for colonoscopy follow‐up and to measure the impact of adjusting referrals to be inline with the guidelines. Design and Setting This is a quantitative five‐stage clinical audit cycle involving a large patient cohort from the Kent and Medway Cancer Network, which includes seven hospitals across four NHS Hospital Trusts and an estimated population of 1.8 million. Participants 3020 patients were waiting for a surveillance colonoscopy. Their notes were reviewed and the indications for colonoscopy were compared with the ACPGBI/BSG 2002 guidelines. Interventions Those patients whose referral to the surveillance colonoscopy waiting list was not found to be compliant were adjusted to be inline with the guidelines. Main outcome measures The impact of adjusting the surveillance colonoscopy waiting list on the diagnostic colonoscopy service was assessed by measuring the average waiting times for a colonoscopy before and after the intervention. Results Around 22% (n = 664) of surveillance colonoscopy referrals were inline with the guidelines, 51% (n = 1540) could be cancelled from the list and 27% (n = 816) could be given a new date. Implementing these recommendations reduced the average wait for a diagnostic colonoscopy from 76.8 to 56.0 days (P = 0.0022). Conclusion Following guidelines for surveillance colonoscopy can reduce waiting times for diagnostic colonoscopy. This allows a faster patient journey for diagnostic colonoscopy and a uniform plan for duration and frequency of surveillance colonoscopy. However, this action promoted serious debate on the social, moral and ethical issues.     

Outcomes and survival analysis of old‐to‐old simultaneous pancreas and kidney transplantation

Outcomes of old‐donor simultaneous pancreas–kidney transplantation (SPKT) have not been thoroughly studied. Scientific Registry of Transplant Recipients data reported for SPKT candidates receiving dialysis wait‐listed between 1993 and 2008 (n = 7937) were analyzed for outcomes among those who remained listed (n = 3301) and of SPKT recipients (n = 4636) using multivariable time‐dependent regression models. Recipients were stratified by donor/recipient age (cutoff 40 years) into: young‐to‐young (n = 2099), young‐to‐old (n = 1873), old‐to‐young (n = 293), and old‐to‐old (n = 371). The overall mortality was 12%, 14%, 20%, and 24%, respectively, for those transplanted, and 50% for those remaining on the waiting list. On multivariable analysis, old‐donor SPKT was associated with significantly higher overall risks of patient death, death‐censored pancreas, and kidney graft failure in both young (73%, 53%, and 63% increased risk, respectively) and old (91%, 124%, and 85% increased risk, respectively) recipients. The adjusted relative mortality risk was similar for recipients of old‐donor SPKT compared with wait‐listed patients including those who subsequently received young‐donor transplants (aHR 0.95; 95% CI 0.78, 1.12) except for candidates in OPOs with waiting times ≥604 days (aHR 0.65, 95% CI 0.45–0.94). Old‐donor SPKT results in significantly worse graft survival and patient mortality without any waiting‐time benefit as compared to young‐donor SPKT, except for candidates with expected long waiting times.     

The association between referral source and stage of disease in patients with colorectal cancer

Objective The colorectal fast track (FT) referral system was set up to ensure patients with suspected cases of colorectal cancer (CRC) received prompt access to specialized services. The aim of this study was to ascertain the association between referral source and the time it took to be seen by a colorectal surgeon to establish whether referral source had any association with the stage of disease at presentation in patients with CRC. Method Consecutive patients with newly diagnosed CRC presenting between October 2002 and September 2004 were identified retrospectively. Mode of presentation, symptoms, treatment and histopathology data were analysed. Results Data for 193 patients were analysed. Ninety seven patients (50%) presented via the FT system, 43 (22.5%) from nonfast track outpatient sources (NFT) and 53 (27.5%) as emergencies. NFT patients took significantly longer to be seen by a colorectal specialist than FT patients (median 69 vs 31 days; P < 0.001) and to initiation of treatment (median 57.5 vs 42.5 days; P = 0.001). Overall 152 patients (79%) presented with symptoms that met the FT criteria. A significantly lower number of NFT (P = 0.001) and emergency patients (P < 0.001) presented with FT symptoms compared with patients referred through the FT system. There was no significant difference between referral groups in patients undergoing surgery with potentially curative intent or stage of disease. Conclusion Nonfast track referral leads to a significant delay in being seen by a specialist and in initiation of treatment but no association with more advanced stage of disease or a reduction in potentially curative surgery was found.     

Familial colorectal cancer risk assessment needs improvement for more effective cancer prevention in relatives

Aim

Twelve to thirty % of colorectal cancer (CRC) patients and relatives with an increased familial risk of CRC are referred for preventive measures. New guidelines recommend genetic counselling for high‐risk families and surveillance colonoscopy for moderate‐risk families. Assessment of familial risk of CRC and referral rates for these preventive measures were determined 1 year after the introduction of new guidelines.

Method

Assessment of familial risk of CRC and referral for preventive measures were measured in clinical practice among 358 patients with CRC in 18 hospitals using medical records and questionnaires. Additionally, a knowledge survey was performed among 312 clinicians.

Results

Sixty‐seven % of patients with an increased familial risk (n = 65/97) were referred for preventive measures, as were 23% (61/261) of low‐risk patients. The uptake of genetic counselling in high‐risk families was 33% (12/36). The uptake of surveillance colonoscopy in moderate‐risk families was 34% (21/61). In the knowledge survey clinicians correctly determined familial risk in 55% and preventive measures in 65% of cases.

Conclusion

Currently 67% of individuals with an increased familial risk of CRC were referred for preventive measures. Only one‐third were referred in accordance with guidelines.

     

Risk of colorectal advanced neoplasia in patients with acute diverticulitis with and without previous colonoscopy

Background and Aim

Guidelines recommend a colonoscopy after an episode of complicated diverticulitis and after a first episode of uncomplicated diverticulitis. The influence of a previous colonoscopy on postdiverticulitis colonoscopic findings has not been studied. The aim of this work was to examine the incidence of adenoma detection rate (ADR), advanced adenoma (AA) and colorectal cancer (CRC) in patients with diverticulitis with and without previous colonoscopy.

Method

This was a retrospective case–control study of subjects with acute diverticulitis. Subsequent and previous colonoscopies were abstracted for ADR, AA and CRC diagnoses. The incidence of neoplasia was compared between patients with and without previous colonoscopy and also with that of a screening population.

Results

Compared with a healthy control group (n = 975), diverticulitis patients without prior colonoscopy (n = 325) had a significantly higher ADR (26.8% vs. 20.5%, p = 0.019) and invasive CRC rate (0.9% vs. 0%, p = 0.016). Risk factors for advanced neoplasia included age ≥ 70 years and complicated diverticulitis. Among subjects with diverticulitis and previous colonoscopy (n = 124), only one patient developed AA and there were no cancer cases.

Conclusions

A previous normal colonoscopy within 5 years before diverticulitis probably overshadows other risk factors for findings of advanced neoplasia and should be considered in the decision to repeat a colonoscopy.     

Use of adjuvant,preoperative chemo-radiotherapy in patients with locally advanced rectal cancer

Background: The objective of this study was to perform a non‐randomised prospective examination of the efficacy of adjuvant, preoperative chemo‐radiotherapy in patients with locally advanced rectal cancer. Methods: Between 1996 and 2001, patients presenting with biopsy‐proven, locally advanced, rectal cancers within 12 cm of the anal verge were referred for a long course of adjuvant chemo‐radiotherapy prior to their surgery. Locally advanced lesions were defined by either: (i) endoanal ultrasound showing at least full thickness penetration of the rectal wall (i.e. T3, T4); (ii) abdominal computed tomography scan showing infiltration of adjacent structures, or; (iii) clinical examination demonstrating a fixed lesion. All patients were followed through the hospital colorectal unit. A Kaplan?Meier survival analysis was used to determine survival and local recurrence rates. Results: There were 60 patients with a mean age of 61.5 years (range 33?77 years) with a sex distribution of males to females of 1.7?1.0. Curative resections were performed in 81% of these patients. The remainder (n = 12) were found to have either metastatic disease at operation (n = 5), inoperable disease (n = 2), or had positive resection margins on histology (n = 7). The mean follow up was 2.1 years (maximum 5.1 years). The overall 2‐year survival rate was 86.1% (95% CI ±5.4%). In patients undergoing curative resections, the overall 2‐year survival rate was 91.4% (95% CI ±4.8%), and the 2‐year disease free survival rate was 85.1% (95% CI ±6.2%). The 2‐year local recurrence rate was 7.5%. Conclusions: The use of adjuvant, preoperative, chemo‐radiotherapy in patients with locally advanced rectal cancer is associated with high short‐term survival and a low recurrence rate.     

T4 colorectal cancer: is laparoscopic resection contraindicated?

Aim T4 colorectal cancer remains a contraindication for laparoscopy. It is argued that the risk of incomplete resection could be higher than in open surgery. Furthermore, difficulty in dissection could lead to a very high rate of conversion. There is little information on this. The study aimed at assessing feasibility and operative and oncologic results of laparoscopic resection for T4 colorectal cancer. Method Between 2006 and 2009, 39 patients with colorectal cancer with suspected involvement of another organ (T4) on computed tomography scanning and/or magnetic resonance imaging were included. The cancers were in the right colon (n = 18), left colon (n = 9) and rectum (n = 12). The distribution of possible organ involvement was abdominal or pelvic side‐wall (n = 21), urinary bladder (n = 4), small bowel or colon (n = 6), vagina and ovary (n = 3), prostate or seminal vesicles (n = 3) and duodenum (n = 2). Results The overall conversion rate was 18%. Postoperative mortality and morbidity were 2.5 and 33%, respectively. Clinical anastomotic leakage rate was 15% (n = 6). Abdominal reoperation was required in three (7%) patients. Pathological invasion to other organs (pT4) was confirmed in 30 (77%) patients. The R1 resection rate was 13% (4 of 30). After a median follow up of 19 months (range 1.5–45 months), the overall survival and disease‐free survival rates were 97 and 89%, respectively. Conclusion This study suggests that laparoscopic surgery is feasible for colorectal T4 cancer resection. Laparoscopy cannot therefore be considered an absolute contraindication for T4 colorectal cancer.     

Invasive colorectal cancer within 5 years of negative colonoscopy in a Japanese population

Aim Colonoscopy provides imperfect protection against colorectal cancer (CRC). In an attempt to improve cancer detection we evaluated the clinical features of invasive CRC detected within 5 years of a negative colonoscopy. Method The details of colonoscopies performed in a rural hospital in Japan were prospectively recorded at the time of the examination. The patients were followed over 5 years for the subsequent occurrence of cancer. Results In a 5‐year period, 10 148 patients underwent colonoscopy and 202 without previous colonoscopy were diagnosed with invasive CRC. Of 3212 patients with a colonoscopy negative for cancer, nine developed invasive cancer within 5 years. The ratios for invasive CRC detected without/with previous colonoscopy were 60:1 in the rectum, 54:1 in the sigmoid colon, 15:1 in the descending colon, 28:0 in the transverse colon, 31:5 in the ascending colon and 14:1 in the caecum (P = 0.041). The ratio between left‐ and right‐sided colonic cancer was also significantly different (129:3 and 45:6, P = 0.0078). Six (67%) of the invasive CRCs were in the ascending colon or caecum. Five of six patients with invasive CRC in the ascending colon and caecum had right‐sided small adenomas at prior colonoscopy. Conclusion The majority of early/missed CRCs were right‐sided and associated with prior right‐sided colonic adenomas. Repeated colonoscopy of patients with right‐sided adenomas at a shorter surveillance interval deserves consideration.     

Clostridium septicum and malignancy

Background: Clostridium septicum is known to be associated with malignancy or immunosuppression. It has a variable clinical presentation and is associated with a high mortality. The aim of the present study was to review the experience at St George Hospital, Sydney, over a 10‐year period, with particular reference to the association of this condition with colorectal cancer. Methods: The records of five patients with blood culture‐proven Clostridium septicum infection, among a larger group of 31 patients with clostridial infections, presenting to St George Hospital between 1990 and 2000 were reviewed. Results: Associated malignancy was found in four (80%) of the patients with Clostridium septicum infection. Two infections were related to colorectal cancer, two to haematological malignancies and one to radiation‐induced recto‐urethral fistula. Those patients who had colorectal cancer presented with septicaemia and vague abdominal symptoms. Conclusions: Clostridium septicum infections have a strong association with malignancy. When this infection occurs without an obvious underlying aetiology there should be a high index of suspicion about associated malignancy. In the absence of haematol­ogical malignancy a colonoscopy is warranted. Early diagnosis and aggressive treatment is essential in order to improve prognosis.     

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BackgroundRecent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.MethodsPubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.ResultsTwenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.ConclusionED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.     

Postoperative recurrence of Crohn’s disease: impact of endoscopic monitoring and treatment step‐up

Aim Eighty per cent of patients with Crohn’s disease require surgery, of whom 70% will require a further operation. Recurrence occurs at the anastomosis. Although often recommended, the impact of postoperative colonoscopy and treatment adjustment is unknown. Method Patients with a bowel resection over a 10‐year period were reviewed and comparison made between those who did and did not have a postoperative colonoscopy within 1 year of surgery, and those who did or did not have a step‐up in drug therapy. Results Of 222 patients operated on, 136 (65 men, mean age 33 years, mean disease duration 8 years, median follow‐up 4 years) were studied. Of 70 patients with and 66 without postoperative colonoscopy, clinical recurrence occurred in 49% and 48% (NS) and further surgery in 9% and 5% (NS). Eighty‐nine per cent of colonoscoped patients had a decision based on the colonoscopic findings: of these, 24% had a step‐up of drug therapy [antibiotics (n = 10), aminosalicylates (n = 2), thiopurine (n = 5), methotrexate (n = 1)] and 76% had no step‐up in drug therapy. In colonoscoped patients clinical recurrence occurred in 9 (60%) of 15 patients with, and 23 (49%) of 47 without step‐up and surgical recurrence in 2 (13%) of 15 and 4 (9%) of 47 (NS). Conclusion Clinical recurrence occurs in a majority of patients soon after surgery. In this cohort, there was no clinical benefit from colonoscopy or increased drug therapy within 1 year after operation. However, the response to the endoscopic findings was not standardized and immunosuppressive therapy was uncommon. Standardizing timing of colonoscopy and drug therapy, including more intense therapy, may improve outcome, although this remains to be proven.     

Increasing access to renal transplantation in India through our single‐center kidney paired donation program: a model for the developing world to prevent commercial transplantation

Because access to transplantation with HLA‐desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end‐stage renal disease (ESRD) patient in India. We present a government and institutional ethical review board approved study of 56 ESRD patients [25 two‐way and 2 three‐way pairs] who consented to participate in KPD transplantation at our center in 2013, performed to avoid blood group incompatibility (n = 52) or positive cross‐match (n = 4). All patients had anatomic, functional, and immunologically comparable donors. The waiting time in KPD was short as compared to deceased donor transplantation. Laparoscopic donor nephrectomy was performed in 54 donors. Donor relationships were spousal (n = 40), parental (n = 13), others (n = 3), with median HLA match of 1. Graft survival was 97.5%. Three patients died with functioning graft. 16% had biopsy‐proven acute rejection. Mean serum creatinine was 1.2 mg/dl at 0.73 ± 0.32 months follow‐up. KPD is a viable, legal, and rapidly growing modality for facilitating LDRT for patients who are incompatible with their healthy, willing living donor. To our knowledge, this is the largest single‐center report from India.     

Does the laparoscopic colorectal surgery learning curve adversely affect the results of colorectal cancer resection? A 3‐year prospective study in a district general hospital

Introduction Laparoscopic colorectal surgery is slowly being adopted across the UK. We present a 3‐year prospective study of laparoscopic colorectal cancer resections in a district general hospital. Method Data relating to premorbid, operative and postoperative parameters were recorded for all patients undergoing laparoscopic, open, planned converted (laparoscopic assisted) and unplanned converted resections prospectively from April 2003 to April 2006. Results A total of 238 colorectal resections were performed, 153 of which were for cancer. Of these 44 (29%) were open, 77 (50%) were laparoscopic and 32 (21%) were converted [26 (17%) planned and six (4%) unplanned]. Blood loss was less in the laparoscopic group compared with the open group (P = 0.02) as was intra‐operative fluid replacement (P = 0.01). Time to requiring oral analgesia alone was shorter (P = 0.001) and bowel function returned earlier (P = 0.001) in the laparoscopic group. This is reflected in a trend towards a shorter hospital stay for the laparoscopic group compared with the open group (P = 0.049). The operating time of the laparoscopic group was not significantly longer (P = 0.38). The complication rate was similar between groups (P = 0.31) and the mortality in the laparoscopic group was 1.3%. Conclusion Changing from open to laparoscopic dissection for colorectal cancer is safe even during the initial learning curve. There are clear potential short‐term benefits for patients and the technique can be introduced without penalties in terms of reduced surgical throughput.