Does surgeon fatigue influence outcomes after anterior resection for rectal cancer?

BACKGROUND: The long work hours in surgery may contribute to medical errors and impact patient outcomes. To date, there are no studies investigating outcomes related to fatigue in general surgery. METHODS: All patients undergoing anterior resection between 1994 and 2005 at 2 university hospitals were identified. Cases were categorized as fatigued or nonfatigued and then compared with respect to complications and cancer recurrence. RESULTS: Two hundred seventy patients underwent anterior resection during the study period. Of these, 22 were performed when the surgeon was fatigued. The fatigued and nonfatigued groups had similar preoperative characteristics. The rates of intraoperative complications (fatigued 14%, rested 18%, P = .58), major postoperative complications (fatigued 9%, rested 15%, P = .68), long-term complications (fatigued 31%, rested 31%, P = .9), and local cancer recurrence rates (fatigued 0%, rested 7%, P = .2) were not significantly different between the 2 groups. CONCLUSIONS: Surgeon fatigue did not influence outcomes after anterior resection for rectal cancer.     

Should 'doughnut' histology be routinely performed following anterior resection for rectal cancer?

Stapled low anterior resection is widely employed in the treatment of rectal adenocarcinoma. The technique yields two tissue 'doughnuts' which are often submitted for histological examination. This process is labour intensive and not part of the minimum data set for colorectal cancer histopathology reports. A consecutive series of anterior resection doughnuts from 125 patients was reviewed retrospectively to assess the impact of doughnut pathology on the management of patients. Four doughnuts had a histological abnormality reported but none of these altered treatment. Routine histological examination of 'doughnuts' is not beneficial to the management of patients undergoing surgery for rectal adenocarcinoma.     

What is a safe distal resection margin in rectal cancer patients treated by low anterior resection without preoperative radiotherapy?

Aim The aim of this study was to examine what constitutes an acceptable distal resection margin (DRM) when performing sphincter‐saving surgery for rectal cancer without preoperative radiotherapy. Method This national study consisted of 3571 patients for whom information on DRM was available and who were radically treated by anterior resection between 1993 and 2004. Of these, 3342 (93.5%) patients had not received preoperative radiotherapy. The DRM was measured on fixed specimens. Results The 5‐year local recurrence rate was 14.5% for patients with a DRM of 0–10 mm compared to 9.6% for patients with a DRM of 11–20 mm, 8.9% for a DRM of 21–30 mm, 7.0% for a DRM of 31–40 mm, 7.7% for a DRM of 41–50 mm and 8.7% for a DRM of > 50 mm. After adjustment for other independent prognostic factors, a DRM of 0–10 mm was found to have significant impact on local recurrence. The DRM had no impact on distant metastases or overall survival. Conclusion For rectal cancer patients treated without radiotherapy, a DRM of > 10 mm is recommended.     

How safe is adjuvant chemotherapy and radiotherapy for rectal cancer?

Over the last three decades, a series of clinical trials have led to the use of adjuvant pelvic radiotherapy and chemotherapy in high-risk (T3-4 or N1) rectal cancer. There is a need to improve patient selection in order to identify the group most at risk for recurrent disease. The toxicity of adjuvant therapy should be factored into this consideration. The optimal sequencing of adjuvant therapy before or after surgery, the use of short- or long-course radiotherapy, and the utility of concurrent chemotherapy is currently being examined in randomized controlled trials (RCTs). The aim of this report was to review the morbidity and mortality in all RCTs of adjuvant therapy for rectal cancer.     

Repeated hepatic resection for colorectal liver metastases: is this concept safe and feasible?

European Surgery - The beneficial outcomes of hepatectomy in patients with colorectal metastases have encouraged the attempts of repeated hepatectomy in patients with recurrent disease. Although...     

Simplification of total mesorectal excision with colonic J-pouch anal anastomosis for middle and lower rectal cancer: One surgeon’s experience

PURPOSE: The introduction of total mesorectal excision (TME) has dramatically improved local control of rectal cancer. Yet, despite its complexity, there is no clear technical explanation of this procedure in the text references. Thus, we attempted to simplify the TME procedure according to its original concept. METHODS: Our procedure has three principles: posterolateral dissection, which is helpful for performing complete TME with autonomic nerve preservation; detachment of the hiatal ligament, which enables mobilization of the whole mesorectum and transection of the distal rectum just above the anal canal; and colonic J-pouch anal anastomosis to support fecal continence. We evaluated our modified TME, focusing on one surgeon's experience. RESULTS: Between 1993 and 2006, 164 patients underwent modified TME, performed by one surgeon (M.K.). Intraoperative blood loss and operating time were both significantly lower than for conventional resection (P < 0.01), and the rate of anastomotic leakage was less than 1%. Modified TME combined with radiotherapy or chemotherapy, or both, also improved prognosis considerably. CONCLUSION: We have succeeded in simplifying the original TME procedure and improved its outcome even further, based on our familiarity with its anatomyoriented elements.     

Ultra-low anterior resection following neoadjuvant chemoradiation for rectal cancer: The end of the 1-cm rule?

The surgical management of rectal cancer has evolved as techniques have improved and the use of preoperative multimodality therapy has gained acceptance as the standard of care. One of the most dynamic areas regarding surgical resection of rectal cancer has been the issue of an oncologically safe distal resection margin. Despite recommendations for the minimum acceptable distal margin shrinking from 5 cm to 2 cm and now to 1 cm over the past several decades, this question remains a topic of intense debate. Such discussion centering on the impact distal margins of resection can critically affect the ability to preserve the anal sphincter complex during rectal resection for cancer. In the present era of the surgical treatment of locally advanced rectal cancers with neoadjuvant chemoradiation, the literature has supported the potential safety of a 1-cm margin for sphincter preservation without a significant risk for unresected microscopic distal intramural spread. More recently, data has emerged demonstrating no statistical difference in oncologic outcomes in terms of local recurrence or overall survival when comparing shorter distal margins to those greater than 1 cm. This review examines the data in support of the 1-cm rule and discusses its validity in light of more recent reports in the modern multidisciplinary treatment era.     

Is low anterior resection for rectal cancer equally efficient in the hands of non-expertised surgeons?

Aim-Background

To evaluate the local recurrence rate after potentially curative low anterior resection and to determine factors influencing local recurrence.

Methods

Two hundred and sixty-nine patients were included in this retrospective clinical study. Studied variables were sex, age, location, size, grade and stage of tumour, surgical and histological clearance margins, height of vessel ligation, total mesorectal excision, number of resected and infiltrated lymph nodes and inflammatory response.

Results

Local recurrence rate was 10%. According to univariate analysis, tumours classified as advanced Astler-Coller stage or over 3 cm in size, mild inflammatory reaction, and more than three infiltrated lymph nodes increased the recurrence rate. Multivariate analysis demonstrated that age under 60, enlarged tumour size, high grade, short clearance margin, presence of infiltrated lymph nodes and mild inflammatory reaction were independent negative prognostic factors.

Conclusions

Low anterior resection is a safe and effective procedure in the hands of general surgeons without expertise in rectal surgery.     

Is palliative resection of the primary tumour,in the presence of advanced rectal cancer,a safe and useful technique for symptom control?

Introduction: At some time, every general surgeon will be faced with the task of trying to decide what to do with a patient who presents with rectal cancer and unresectable distant metastases. How safe is resectional surgery? What sort of palliation may be expected following resection of the primary tumour? In an attempt to answer these questions, the management and outcomes of all patients with rectal cancer and distant metastases, who were primarily referred to the colorectal unit at King Faisal Specialist Hospital were examined. Methods: All patients who underwent primary surgery for rectal cancer in the presence of metastatic disease were identified. The charts of these patients were examined and their morbidity, mortality and survival were determined. Results: Over an 8‐year period 22 patients (average age 54 years) underwent rectal resectional surgery in the presence of metastatic disease. There were 13 men and nine women. The commonest complaint was rectal bleeding. All patients had chest radiographs. Pulmonary metastases were identified in four patients. Nineteen abdominal and pelvic computed tomography scans were performed and eight showed evidence of metastases. Skeletal radiographs in two patients showed evidence of bone metastasis. At operation, intraperitoneal metastases were found in 18 patients. Nine of these were not identified preoperatively. Six patients underwent abdomino‐perineal resection, nine anterior resection and seven a Hartmann's procedure. Eight patients developed a significant postoperative complication and one died 42 days after surgery. The mean length of hospital stay was 18.6 days. Nine patients received preoperative radiotherapy. Four patients had palliative radiotherapy, two for bony, one for liver and one for peritoneal metastases. Patients were followed up for a mean of 1.1 years. During follow up, 11 returned to the emergency room on 24 occasions. Two patients required readmission. No patient had further rectal bleeding. The mean survival was 1.3 years. Conclusion: Patients with rectal cancer and unresectable distant metastases can be successfully palliated by resection of the primary tumour with low morbidity and mortality. The early involvement of a palliative care team facilitates patient management and helps patients enjoy what remains of the rest of their lives at home, in comfort and with good symptom control.     

Preoperative MRI sphincter morphology and anal manometry: can they be markers of functional outcome following anterior resection for rectal cancer?

Aim Good functional outcome following anterior resection (AR) for rectal cancer is an important clinical goal, but its prediction has proven difficult. Assessments such as anal manometry have been advocated as a potential tool but functional anatomy as depicted on MRI has not been investigated. This study looked at whether sphincter complex measurements recorded from preoperative staging MRIs and preoperative anal manometry have any correlation with functional outcome. Method Consecutive patients with rectal adenocarcinoma underwent preoperative manometric assessment and MRI staging. MRIs were assessed with regard to anorectal angle, puborectalis thickness, canal length and external and internal anal sphincter thickness. Functional outcome was categorized into three groups according to the number of adverse postoperative symptoms (frequency, urgency, leakage, diarrhoea, use of pads, use of antidiarrhoeal medication): 0, 1 and ≥2. This was evaluated 1 year following surgery and 6 months following stoma reversal where applicable. Univariate analysis of an ordinal regression model was performed with significance at the 5% level. Results Thirty patients were assessed. No single preoperative manometric parameter proved significant (P > 0.05). Only puborectalis thickness showed a significant (P = 0.01) relationship with the number of adverse symptoms suffered postoperatively. On receiver operating characteristics analysis, a cut‐off value of 3.5 mm gave an optimal sensitivity of 0.5 (95% CI, 0.17–0.83) and specificity of 0.86 (95% CI, 0.64–0.96). Conclusions Measurements of the puborectalis thickness on preoperative staging MRIs for rectal cancer may help predict functional outcome following AR. Prospective assessment of larger numbers with a fully validated continence score are required to evaluate these findings further.     

Intestinal resection and multiple abdominal hernia mesh repair: is the combination safe and feasible?

In a highly advanced era from the point of view of instrumental diagnostic resolution it is, however, not always possible to obtain a precise preoperative diagnosis. Surgery is sometimes the only decisive solution. In April 2003, a 62-year-old male patient was referred to us for umbilical hernia, diastasis recti abdominis and left-sided inguinal hernia; he also complained of pain in the mesogastric-hypogastric region. This site presented with a hard, non-mobile, painful tumefaction at both superficial and deep palpation. The patient was submitted to various diagnostic examinations (pancolonoscopy, CT, X-ray of the digestive tract and angiography), but only surgery allowed us to establish the specific nature of the tumefaction. The operation consisted in the en-bloc removal of an abscess mass affecting intestinal loops, caecum and appendix and at the same time in the repair of the hernia components with the use of prosthesis in a potentially contaminated area. The tumefaction had originated following acute appendicitis episodes that had determined adherences between the appendix, caecum and ileal loops (histologically confirmed). There are situations that require surgery in order to be explicitly diagnosed and solved. Furthermore, although the use of prosthetic materials in the treatment of hernias in association with intestinal resection is an extreme case, it has also been reported in the international literature that nowadays there are no real contraindications to the implantation of a prosthesis in a potentially infected area.     

Surgery for recurrent rectal cancer: higher and wider?

Aim There has been a steady increase in the number of centres that carry out resection of locally recurrent rectal cancer (LRRC). The aim of this review was to highlight the present management and suggest technical strategies that may improve survival and quality of life. Method The review identified relevant studies from an electronic search of MEDLINE and PubMed databases between 1980 and 2011. References in published articles were also reviewed. Results Surgical intervention offers the best hope to control LRRC but the proportion of patients offered this remains small. Certain contraindications previously considered to be absolute should now be thought of as relative. Conclusion Awareness of the surgical options and a willingness to consider more aggressive options may result in more patients being considered for potentially curative resection.     

Acceptance of a 5‐mm distal bowel resection margin for rectal cancer: is it safe?

Aim Acceptance of a short distal bowel margin results in a higher rate of anterior resection but may compromise oncological safety. This study aimed to evaluate the safety of a 5‐mm distal margin. Method A retrospective analysis was carried out of 412 consecutive patients with rectal cancer treated with anterior resection with a negative circumferential resection margin. Radiotherapy was given to 63% of patients with an advanced tumour. The median follow up was 75 months. Results Fewer patients in the group with a distal margin of ≤ 5 mm had a tumour with an advanced pT stage compared to patients in the group with a distal margin of > 5 mm (P = 0.033). Two patients were converted to abdominoperineal resection because of a positive ‘doughnut’, leaving 410 patients, in whom 5.4% (95% CI, 0–11.3%) of the group with a distal margin of ≤ 5 mm had local recurrence at 5 years compared with 4.2% (95% CI, 2.1–6.3%) of the group with a distal margin of > 5 mm (P = 0.726). The corresponding figures for the 5‐year overall survival were 82.4% (95% CI, 72.6–92.2%) vs 76.3% (95% CI, 71.8–80.8%) (P = 0.581). All four anastomotic recurrences occurred in the group with a distal margin of > 5 mm. Conclusion A distal margin of ≤ 5 mm did not compromise oncological safety in patients undergoing preoperative radiation for an advanced rectal cancer.     

Anastomotic salvage after rectal cancer resection using the Turnbull–Cutait delayed anastomosis

Background

Turnbull–Cutait abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) was first described in 1961. Studies have described its use for challenging colorectal conditions. We reviewed our experience with Turnbull–Cutait DCA as a salvage procedure for complex failure of colorectal anastomosis.

Methods

We performed a retrospective cohort study from October 2010 to September 2011, with analysis of postoperative morbidity and mortality.

Results

Seven DCAs were performed for anastomotic complications (3 chronic leaks, 2 rectovaginal fistulas, 1 colovesical fistula, 1 colonic ischemia) following surgery for rectal cancer. Six patients had a diverting ileostomy constructed as part of previous treatment for anastomotic complications before the salvage procedure. No anastomotic leaks were observed. All procedures but 1 were completed successfully. One patient who underwent DCA subsequently required an abdominoperineal resection and a permanent colostomy for postoperative extensive colonic ischemia. No 30-day mortality occurred.

Conclusion

Salvage Turnbull–Cutait DCA appears to be a safe procedure and could be offered to patients with complex anastomotic complications. This procedure could be added to the surgeon’s armamentarium as an alternative to the creation of a permanent stoma.     

Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile?

BACKGROUND: Whether or not superior mesentericoportal venous resection (SM-PVR) associated with pancreaticoduodenectomy (PD) is safe and worthwhile has not been fully confirmed. The aim of the present study was to investigate results of this surgical procedure performed for pancreatic head and periampullary neoplasms. METHODS: As a first analysis, postoperative morbidity and mortality after PD with (n = 31) or without SM-PVR (n = 119) were investigated in 150 patients with pancreatic head and periampullary neoplasms. As a second analysis, rates of margin-negative resection and survival after SM-PVR (n = 21) and without SM-PVR (n = 66) were compared in 87 patients with pancreatic ductal adenocarcinoma of the pancreatic head. In these patients undergoing SM-PVR (n = 21), survival rate was investigated in patients who did (n = 13) and did not (n = 8) undergo a margin-negative resection. RESULTS: In the first analysis, duration of surgery and volume of blood transfused perioperatively were higher in patients undergoing SM-PVR. However, mortality, morbidity rates, and mean hospital stay did not differ between patients who did undergo SM-PVR (31 patients, 3.2%, 48.4%, and 22.2 days, respectively) and who did not (119 patients, 2.5%, 47.1%, 25.9 days, respectively). No postoperative death occurred in the recent part of the present study, since 1994, in patients undergoing SM-PVR. In the second analysis of pancreatic ductal adenocarcinoma, rates of margin-negative resection and 2-year survival did not significantly differ between patients who did and did not undergo SM-PVR (62% and 22%, respectively, versus 73% and 24%). In patients undergoing SM-PVR, survival rate was significantly higher for patients undergoing a margin-negative resection (n = 13) than for patients undergoing a macroscopic or microscopic margin-positive resection (n = 8, 2-year survival = 57.1% versus 0%, P <0.05). CONCLUSION: PD combined with SM-PVR can be performed safely. This surgical procedure is followed by a promising survival rate and can be recommended in order to obtain a margin-negative resection; however, candidates for SM-PVR should be carefully selected.